Obtaining electrocardiography (ECG) data too soon after the return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA) was tied to a higher percentage of false-positive findings for ST-segment elevation myocardial infarction (STEMI), according to results from the PEACE study.
When ROSC to EGC time was ≤7 minutes, the percentage of false-positive ECG findings was 18.5% versus 7.2% for a ROSC-to-ECG time of 8 to 33 minutes (odds ratio 0.34, 95% CI 0.13 to 0.87, P=0.02), and 5.8% for a ROSC-to-ECG time of ≥33 minutes (OR 0.27, 95% CI 0.15 to 0.47, P<0.001), reported Enrico Baldi, MD, of Fondazione IRCCS Policlinico San Matteo in Pavia, Italy, and co-authors.
“This finding supports our hypothesis that, in the early post-ROSC phase, ECG findings could reflect not only the ischemia due to a coronary obstruction but also ischemia due to no blood flow and/or low blood flow during cardiac arrest,” they wrote in JAMA Network Open.
“It may be reasonable to delay post-ROSC ECG by at least 8 minutes after ROSC or repeat the acquisition if the first ECG is diagnostic of STEMI and is acquired early after ROSC,” given that the percentage of false positive ECG findings was three times greater when the data was acquired earlier versus later, the authors advised.
The findings are out of sync with current American Heart Association guidance, which calls for 12-lead ECG immediately after ROSC once initial stabilization has taken place, noted Demetris Yannopoulos, MD, and Rajat Kalra, MD, both of the University of Minnesota Medical School in Minneapolis, in an invited commentary accompanying the study.
The PEACE study findings “challenge important dogmas in resuscitation science and provide important food for thought,” they added, such as previous research indicating that ECGs “obtained soon after ROSC may reflect ST elevation in the absence of significant epicardial stenoses,” and that “there is an inconsistent association with the existence of significant epicardial coronary artery disease among patients without ST elevation on the early electrocardiogram after ROSC.”
Yannopoulos and Kalra highlighted that “delaying electrocardiography after ROSC would allow for some normalization of this disruption and improve the reliability of electrocardiography.”
The retrospective PEACE study enrolled patients (median age 62; 77% male) who were resuscitated from OHCA from Jan. 2015 to Dec. 2018 at one of three European facilities. Eligible patients had to have undergone coronary angiography during hospitalization and have a post-ROSC ECG prior to angiography. Of the 370 total ECGs, 172 were not diagnostic of STEMI and 198 were, according to Baldi and co-authors.
The study’s primary outcome was false positive ECG findings, which the authors defined as the percentage of patients with post-ROSC ECG findings that met STEMI criteria, but who did not show obstructive coronary artery disease on angiography and did not require percutaneous coronary angioplasty (PTCA).
The differences between the three time-based groups remained significant when the data were adjusted for a variety of factors, including:
- Sex: OR 0.32 for ≤7 minutes versus reference 8 to 33 minutes (95% CI 0.12 to 0.85, P=0.02); OR 0.26 versus reference >33 minutes (95% CI 0.14 to 0.47, P<0.001).
- Age: OR 0.34 (95% CI 0.13 to 0.89, P=0.03); OR 0.27 (95% CI 0.15 to 0.46, P<0.001).
- Number of segments with ST-elevation: OR 0.35 (95% CI 0.15 to 0.81, P= 0.01); OR 0.28, 95% CI 0.15 to 0.52, P<0.001)
Study limitations included the retrospective design and small sample size, the endpoint of PCTA rather than identification of a culprit lesion, and STEMI diagnosis based solely on ECG. Also, about 25% of patients who underwent coronary angiography did not have a post-ROSC ECG, and resuscitation quality was not evaluated, the authors noted.
Nonetheless, Baldi’s group suggested that the study results could easily be put into practice to improve OHCA patient outcomes. “Delaying the post-ROSC ECG by at least 8 minutes after ROSC or repeating the acquisition if the first ECG was diagnostic of STEMI and was acquired early after ROSC may be reasonable to correctly identify patients who may benefit from an immediate rather than a delayed coronary angiography,” they wrote.
Yannopoulos and Kalra pointed out that “systematically targeting the specific metabolic, electrolyte, and electromechanical pathways that are impacted during OHCA and the resuscitation process may limit the inaccuracies associated with electrocardiograms soon after ROSC. Importantly, this may concomitantly improve OHCA outcomes.”
Possible approaches to the latter could be “early, high-quality CPR and early defibrillation to maintain adequate coronary and visceral perfusion… The addition of novel agents early after ROSC [to encourage] cardiomyocyte membrane stabilization and prevent the electrical derangement… [and] Reorganizing the public health infrastructure to promote the transfer of patients to expert cardiac arrest hubs, where the rapid institution of advanced hemodynamic strategies (such as veno-arterial ECMO) can be sought,” they added.
-
Early ECG after return of spontaneous circulation (ROSC) demonstrated a higher percentage of false-positive ECG findings for ST-segment elevation myocardial infarction (STEMI) after an out-of-hospital cardiac arrest.
-
False positive ECG findings among those performed ≤7 minutes after ROSC was significantly higher than those performed between 8 and 33 minutes and those performed >33 minutes.
Shalmali Pal, Contributing Writer, BreakingMED™
The PEACE study was funded by the European Resuscitation Council Research Net.
Baldi reported support from the European Union Horizon 2020 Research and Innovation Program of ESCAPE-NET. Co-authors reported support from, and/or relationships with, Bard, Emcools, Zoll Medical, Zoll Circulation, Boston Scientific, Boston Scientific Consultant, Microport Consultant, Microport, and Biosense Webster.
Yannopoulos reported support from the NIH. Kalra reported no relationships relevant to the contents of this paper to disclose.
Cat ID: 358
Topic ID: 74,358,254,570,730,358,192,925
