Cardiac Catheterization in OHCA Survivors: AHA/ACC and ESC Recommendations
Visual Classification Chart
🟢 CLASS I (GREEN) - RECOMMENDED
Emergency cardiac catheterization is RECOMMENDED for:
- OHCA survivors with ST-elevation on post-ROSC ECG 1, 2
- OHCA survivors with new left bundle branch block 3
🟡 CLASS IIa (YELLOW) - REASONABLE
Emergency cardiac catheterization is REASONABLE for:
- Comatose OHCA survivors WITHOUT ST-elevation who are electrically unstable (recurrent arrhythmias) 1, 2, 4
- Comatose OHCA survivors WITHOUT ST-elevation who are hemodynamically unstable 1, 2, 4
- Awake OHCA survivors where coronary angiography would otherwise be indicated 1
🟠 CLASS IIb (ORANGE) - MAY BE CONSIDERED
Emergency cardiac catheterization MAY BE CONSIDERED for:
- Select comatose OHCA survivors WITHOUT ST-elevation, suspected cardiac origin, but hemodynamically stable 1
- ESC: Within 2 hours if no obvious non-cardiac cause identified 1, 2
🔴 CLASS III (RED) - NOT RECOMMENDED
Delayed/selective approach is PREFERRED for:
- Hemodynamically stable, comatose OHCA survivors WITHOUT ST-elevation and WITH obvious non-cardiac cause 3, 4
Key Algorithmic Approach
Step 1: Immediate Post-ROSC ECG Assessment
Obtain 12-lead ECG immediately after ROSC 2, 3
- If ST-elevation or new LBBB present → Activate cath lab emergently (Class I) - over 80% have acute coronary lesion requiring intervention 2, 3
- If NO ST-elevation → Proceed to Step 2
Step 2: Assess for Non-Cardiac Causes
Perform focused evaluation 3:
- History (witnessed trauma, drowning, drug overdose, etc.)
- Physical examination
- Chest X-ray
- Consider CT scan if indicated
If obvious non-cardiac cause identified → Consider delayed/selective catheterization 3, 4
If NO obvious non-cardiac cause → Proceed to Step 3
Step 3: Assess Hemodynamic and Electrical Stability
Evaluate for:
- Hemodynamic instability: Persistent hypotension requiring vasopressors, cardiogenic shock 1, 2
- Electrical instability: Recurrent ventricular arrhythmias 1, 2, 4
If EITHER present → Emergency catheterization (Class IIa) 1, 2
If BOTH absent AND patient comatose → Consider emergency catheterization within 2 hours (ESC approach) or delayed selective approach (recent RCT evidence) 1, 4
Critical Management Principles
Do NOT Delay Catheterization For:
- Therapeutic hypothermia/targeted temperature management - can be safely combined with PCI 1, 2, 3, 5
- Hemodynamic optimization - proceed to cath lab while managing hypotension with vasopressors 5
- Comatose state alone - if ST-elevation present, comatose status is NOT a contraindication 1, 3
Avoid Common Pitfalls:
- Do NOT give additional large-volume cold fluid boluses for post-ROSC hypotension - increases risk of re-arrest and pulmonary edema without mortality benefit 5
- Do NOT use comatose state as sole reason to defer catheterization in ST-elevation patients 1, 3
- Do NOT delay for "stabilization" in electrically or hemodynamically unstable patients 2, 5
Evidence Quality and Recent Updates
Strength of Recommendations:
The Class I recommendation for ST-elevation is based on consistent observational data showing large benefit, though not randomized trials 1, 2, 3. The Class IIa recommendation for non-ST-elevation with instability represents expert consensus based on very-low-quality evidence from 513 patients in meta-analysis 1, 3.
Recent Contradictory Evidence:
Important divergence: Recent 2023 randomized controlled trials show NO benefit of routine early catheterization in hemodynamically stable, comatose OHCA survivors without ST-elevation 4. This contrasts with earlier observational data and explains why this remains Class IIb (may be considered) rather than Class I 4.
ESC-Specific Approach:
The ESC recommends considering catheterization within 2 hours for non-ST-elevation patients without obvious non-cardiac cause, particularly if hemodynamically unstable 1, 2. This is more aggressive than the AHA/ACC approach for stable patients 1.
Integration with Post-Arrest Care Bundle
Concurrent management during transport to cath lab 5: