Early Cardiac Catheterization in OHCA with STEMI
For adult patients with out-of-hospital cardiac arrest (OHCA) and ST-elevation on ECG after return of spontaneous circulation (ROSC), emergency cardiac catheterization should be performed immediately, as more than 80% of these patients have an acute coronary lesion requiring intervention and this approach improves both hospital mortality and neurologically favorable survival. 1, 2
Primary Evidence Base
The recommendation for immediate catheterization in OHCA with STEMI is grounded in several key findings:
High prevalence of acute coronary lesions: Over 80% of OHCA patients with ST-elevation have an acute coronary lesion requiring intervention, making emergency angiography the standard of care 2
Mortality benefit: Emergency cardiac catheterization laboratory evaluation is recommended over delayed or no catheterization in select adult patients with ROSC after OHCA of suspected cardiac origin with ST-elevation on ECG 1
Time-dependent outcomes: Every additional minute to ROSC increases the hazard of death by 1.7%, while successful reperfusion in response to primary PCI reduces the hazard of death by 65% 3
Clinical Implementation Algorithm
Immediate Actions Upon ROSC with STEMI:
Obtain 12-lead ECG immediately after ROSC to identify ST-elevation (Class I recommendation) 2
Activate catheterization laboratory emergently without delay for hemodynamic optimization—proceed to cath lab while simultaneously managing hypotension with vasopressors 2, 4
Do not delay for comatose state: Clinical findings of coma before PCI are common in OHCA patients and are not a contraindication to immediate angiography and PCI 1, 2
Initiate targeted temperature management immediately for comatose post-arrest patients (target 32-34°C for 12-24 hours), which can be safely combined with emergency cardiac catheterization and should not delay PCI 2, 4
Expected Outcomes:
High survival rates: In paramedic-identified STEMI patients treated with primary PCI following OHCA resuscitation, in-hospital mortality is only 4.1%, with 30-day mortality of 4.1% and one-year mortality of 5.2% 5
Neurological recovery: Full neurological recovery is recorded in 85.1% of those who survive to discharge when conscious after OHCA, though only 30.6% of survivors who were admitted unconscious achieve full neurological recovery 3
Survival to discharge: Overall, 76.5% of OHCA patients with STEMI survive to hospital discharge when treated with primary PCI 3
Critical Pitfalls to Avoid
Do not delay catheterization for additional diagnostic workup in the presence of ST-elevation—the diagnosis is clear and time to reperfusion directly impacts mortality 2, 3
Avoid excessive cold IV fluid boluses during resuscitation, as rapid infusion of large volumes of cold fluids increases risk of cardiac re-arrest and pulmonary edema without mortality benefit 4
Do not perform multivessel PCI at the time of primary PCI in the setting of cardiogenic shock, as this is associated with higher rates of death or renal replacement therapy (Class 3: Harm) 6
Supporting Systems of Care
Prehospital STEMI activation of the catheterization laboratory reduces treatment delays and improves patient mortality 1
Direct transport to PCI-capable facilities for patients diagnosed with STEMI by EMS in the out-of-hospital setting is reasonable, bypassing closer EDs as necessary 1
Transfer to PCI-capable centers is justified for ST-elevation OHCA patients presenting to non-PCI-capable hospitals 2
The strength of this recommendation is based on consistent guideline consensus from the American Heart Association and American College of Cardiology 1, 2, supported by observational data demonstrating that high-risk patients with STEMI benefit from an early invasive strategy 7, with particularly strong outcomes when rapid reperfusion is achieved 3, 5.