What is the recommended management for an out-of-hospital cardiac arrest (OHCA) survivor with a diagnosis of ST-elevation myocardial infarction (STEMI) on post-return of spontaneous circulation (ROSC) electrocardiogram (ECG)?

Direct Transfer to PCI-Capable Centers for OHCA Survivors with Post-ROSC STEMI

OHCA survivors with ST-elevation on post-ROSC ECG should be transferred emergently and directly to a PCI-capable center for immediate coronary angiography and primary PCI, as this represents a Class I recommendation with strong evidence demonstrating improved survival and neurologically intact outcomes.

Guideline-Based Recommendations

Immediate Transfer Strategy

The American Heart Association explicitly recommends emergency coronary angiography for OHCA patients with suspected cardiac etiology and ST-elevation on ECG (Class I, LOE B-NR), performed emergently rather than later in the hospital stay or not at all 1. The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guidelines reinforce that patients with cardiac arrest and STEMI who have been resuscitated should preferentially be transferred by EMS to a PPCI-capable center (Class I, LOE C-LD) 1.

Prehospital Triage Protocols

• EMS should bypass closer non-PCI-capable facilities to transport directly to PCI centers when first medical contact-to-balloon times can be achieved in <90 minutes and transport times are relatively short (<30 minutes) 1.
• Field 12-lead ECG acquisition with transmission to the receiving hospital is recommended to facilitate early catheterization laboratory activation 1.

Supporting Evidence from Clinical Studies

Survival Outcomes

Multiple observational studies demonstrate excellent survival rates when OHCA-STEMI patients receive immediate PCI:

• A 2014 UK study showed 66% survival to hospital discharge when ambulance clinicians conveyed resuscitated OHCA-STEMI patients directly to a Heart Attack Centre 2.
• A 2015 study of 132 consecutive OHCA-STEMI patients treated with primary PCI demonstrated 76.5% survival to hospital discharge, with only one additional death in the first year 3.
• A 2022 Australian study of paramedic-identified STEMI patients with OHCA showed in-hospital mortality of only 4.1%, 30-day mortality of 4.1%, and one-year mortality of 5.2% 4.

Time-Dependent Benefits

Every minute delay to return of spontaneous circulation (ROSC) significantly impacts outcomes:

• Each additional minute to ROSC increases the hazard of death by 1.7% and increases odds of neurological deficit by 7.0% 3.
• Successful reperfusion with primary PCI reduces the hazard of death by 65% 3.
• Patients with OHCA had longer median times from prehospital STEMI identification to reperfusion compared to non-arrest STEMI patients (97 vs 87 minutes), emphasizing the need for streamlined transfer protocols 4.

Clinical Algorithm for Management

Step 1: Post-ROSC ECG Assessment

• Obtain 12-lead ECG immediately after achieving ROSC 1, 5.
• If ST-elevation is present, activate catheterization laboratory and arrange direct transfer to PCI-capable center 1.

Step 2: Consciousness Status Assessment

Consciousness level should NOT delay transfer or catheterization:

• For patients who are awake/noncomatose after ROSC with STEMI: proceed immediately to primary PCI (outcomes comparable to STEMI patients without cardiac arrest) 1.
• For comatose patients with favorable prognostic features and STEMI: proceed to primary PCI to improve survival (Class I, LOE B-NR) 1.
• For comatose patients with unfavorable prognostic features and STEMI: primary PCI may be reasonable after individualized assessment (Class IIb, LOE C-LD) 1.

Step 3: Concurrent Post-Arrest Care During Transfer

• Initiate targeted temperature management immediately; do not delay catheterization for cooling 5, 6.
• Manage hypotension with vasopressors rather than additional fluid boluses during transport 6.
• Maintain ventilation at 10-12 breaths/min targeting PETCO2 35-40 mmHg 6.

Neurological Outcomes

Neurologically intact survival is achievable even in high-risk subgroups:

• Full neurological recovery was recorded in 85.1% of survivors discharged after primary PCI 3.
• Among the high-risk subgroup admitted unconscious requiring ICU treatment, 30.6% achieved neurologically intact survival 3.
• In patients treated with primary PCI after OHCA, 5-year survival rate was 99% with good cerebral performance category in 92% 7.

Critical Pitfalls to Avoid

Do not delay transfer or catheterization for:

• Hemodynamic optimization—proceed to cath lab while simultaneously managing hypotension 6.
• Initiation of therapeutic hypothermia—this can be safely combined with PCI 1, 5, 6.
• Comatose state alone—over 80% of STEMI-OHCA patients have acute coronary lesions requiring intervention 5, 8.

Do not transfer to non-PCI-capable facilities first:

• Direct transfer to PCI centers is associated with improved survival compared to initial presentation at non-PCI hospitals with subsequent transfer 1.

Evidence Quality Considerations

The recommendations are based primarily on observational studies (LOE B-NR to C-LD) rather than randomized controlled trials 1, 8. However, the consistency of findings across multiple studies and the magnitude of survival benefit (76-77% hospital survival vs <10% historical survival for comatose OHCA) provide compelling support for this strategy 3, 4, 2, 7.