What is the ideal timeframe for transferring out-of-hospital cardiac arrest survivors with suspected cardiac origin to a Percutaneous Coronary Intervention (PCI)-capable hospital?

Transfer Timing for Out-of-Hospital Cardiac Arrest Survivors to PCI-Capable Hospitals

Out-of-hospital cardiac arrest survivors with ST-elevation on ECG should be transferred immediately to a PCI-capable hospital, bypassing closer non-PCI facilities if necessary, as this strategy is associated with significantly improved survival (adjusted OR 2.47) regardless of transport time. 1, 2

Decision Algorithm Based on ECG Findings

For Patients WITH ST-Elevation After ROSC

• Immediate transfer to a PCI-capable center is indicated, even if this requires bypassing the nearest hospital. 1, 2
• Direct transport to PCI centers improves survival to hospital discharge compared to transport to non-PCI hospitals (33.5% vs 14.6% survival), with this benefit persisting across all transport time intervals from 1-5 minutes up to >30 minutes. 2
• The maximum acceptable additional transport delay is approximately 14 minutes—meaning you can bypass a closer hospital if the added travel time to reach a PCI center is less than 14 minutes. 3
• This recommendation applies regardless of whether the patient is awake or comatose, as both groups benefit from immediate access to PCI capabilities. 1

For Patients WITHOUT ST-Elevation After ROSC

• Do not perform immediate coronary angiography in stable post-arrest patients without ST-elevation (Class III: No Benefit recommendation). 1
• These patients should be transported to the nearest appropriate facility capable of providing comprehensive post-cardiac arrest care, including therapeutic hypothermia if indicated. 4
• Coronary angiography can be considered later if clinical indicators of ongoing ischemia develop. 4

Timing of Coronary Intervention Upon Arrival

For Awake/Non-Comatose Patients with STEMI

• Proceed directly to primary PCI upon arrival at the PCI center, as these patients have survival rates comparable to STEMI patients who never arrested (95-100% survival in optimal circumstances). 4, 1

For Comatose Patients with STEMI

• Proceed to immediate coronary angiography and PCI if indicated when favorable prognostic features are present: witnessed arrest, bystander CPR, shockable rhythm (VF/pVT), and CPR duration <30 minutes. 4, 1
• Emergency coronary angiography in unconscious post-arrest patients is independently associated with improved in-hospital survival (HR 2.32), and successful emergency PCI further improves outcomes (HR 2.54). 5
• Immediate PCI combined with therapeutic hypothermia is feasible and safe in comatose patients. 4

Evidence Supporting the Transfer Strategy

The evidence strongly favors direct transport to PCI centers over a strategy of initial stabilization at non-PCI facilities:

• Eleven studies demonstrated improved outcomes (including left ventricular function, in-hospital mortality, long-term mortality, and composite endpoints of death/reinfarction/stroke) for patients diagnosed with STEMI in the prehospital setting and brought directly to PCI centers compared to those transferred secondarily from non-PCI hospitals. 4
• Immediate PCI after out-of-hospital cardiac arrest is associated with reduced short-term mortality (adjusted OR 0.71) and long-term mortality (adjusted HR 0.44) compared to no coronary angiography. 6
• The benefit of direct transport to PCI centers persists even with transport times exceeding 30 minutes, with adjusted survival remaining significantly better across all time intervals studied. 2

Critical Pitfalls to Avoid

Do Not Delay Transfer While Assessing Neurologic Recovery

• Waiting for neurologic improvement before initiating transfer results in missed opportunities to improve both cardiac and neurologic outcomes. 1
• Delay in performing coronary angiography is independently associated with increased in-hospital mortality (HR 0.95 per day of delay). 5

Do Not Keep Patients at Non-PCI Facilities for Observation

• Even patients who appear stable after ROSC can deteriorate or experience recurrent arrest. 1
• The median door-in-door-out time at non-PCI hospitals should be minimized, with systems achieving times of 71 minutes showing better outcomes than those with 120-minute delays. 4

Do Not Assume Comatose Patients Cannot Benefit

• While overall survival-to-discharge in comatose post-arrest patients may be <10%, those with witnessed arrest, shockable rhythm, and brief CPR duration have significantly improved survival with immediate PCI. 4, 1
• One study showed survival rates as high as 95-100% in patients with witnessed VF arrests of short duration who underwent immediate PCI. 4

System-Level Considerations

Regional systems of care should be established with protocols for direct transport of post-arrest patients to PCI-capable cardiac resuscitation centers. 4

• Prehospital 12-lead ECG with transmission or notification to the receiving PCI center reduces time to treatment and improves outcomes. 4
• Systems should aim for first medical contact-to-balloon times that are brief, with coordinated regional responses showing reduced in-hospital mortality compared to transport to the closest hospital. 4
• Shared reimbursement models between referring hospitals, EMS, and receiving PCI centers may be necessary to sustain these systems of care. 4