From the Guidelines
In a cardiac arrest with STEMI where the patient is not alert, immediate resuscitation following ACLS protocols is the priority, with a focus on high-quality CPR, early defibrillation, and establishment of IV/IO access, as recommended by the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1. The management of such cases involves several key steps, including:
- High-quality CPR with minimal interruptions
- Early defibrillation for shockable rhythms
- Establishment of IV/IO access
- Administration of epinephrine 1mg IV/IO every 3-5 minutes
- Consideration of amiodarone 300mg IV/IO bolus for refractory VF/VT, followed by 150mg if needed Once return of spontaneous circulation (ROSC) is achieved, immediate coronary reperfusion via primary PCI is crucial, with a door-to-balloon time target of 90 minutes or less, as emphasized in the 2017 ESC guidelines 1. If PCI is unavailable within 120 minutes, consideration of fibrinolytic therapy, such as alteplase, may be necessary, as outlined in the guidelines 1. Post-ROSC, implementation of targeted temperature management (33-36°C for 24 hours) is recommended if the patient remains comatose, as stated in the 2017 ESC guidelines 1. The underlying pathophysiology involves coronary artery occlusion causing myocardial ischemia and electrical instability, leading to lethal arrhythmias, and rapid reperfusion is essential to salvage myocardium and improve survival chances, as every minute of delay increases mortality risk, highlighting the importance of prompt and effective management, as discussed in the 2018 European Heart Journal publication 1.
From the Research
Arrest with STEMI not alert
- The management of cardiac arrest in patients with ST-elevation myocardial infarction (STEMI) is a complex and challenging issue, with high mortality and morbidity rates 2.
- The use of mechanical chest compression and Impella to facilitate percutaneous coronary intervention (PCI) has been reported as a potential technique to provide good mechanical haemodynamic support and aid early revascularisation in patients with cardiogenic shock and arrest 2.
- In patients with STEMI undergoing primary PCI, ticagrelor has been shown to reduce the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and the composite end point of cardiovascular death, nonfatal MI, and stroke compared with clopidogrel 3, 4.
- However, the optimal management of patients with STEMI who are not alert and require cardiac arrest treatment is not well established, and further research is needed to determine the best approach.
- The role of antithrombotic therapy, including antiplatelet and anticoagulant agents, is crucial in the management of STEMI patients undergoing primary PCI, and the choice of therapy should be individualized based on patient characteristics and clinical presentation 5.
- Aspirin loading has been shown to be a class I recommendation for STEMI patients, but its effects on infarct size limiting have not been fully studied, and further research is needed to determine its optimal use 6.