A new treatment plan that gives a subset of sudden cardiac arrest (SCA) patients early access to the cardiac catheterization laboratory (CCL) has shown promise in boosting survival rates and improving outcomes. Focusing on SCA patients who present in the field with ventricular fibrillation (VF) or ventricular tachycardia (VT), the clinical protocol has these patients move immediately to advanced screening and treatment in the CCL, an approach that has been found to increase these patients’ chances of brain-healthy survival when compared to the current standard approach of further monitoring without early CCL evaluation.1,2,3 Current American Heart Association guidelines call for revived SCA patients to first receive an electrocardiogram to rule out myocardial infarction.4
Among the approximately 300,000 patients who suffer SCA outside of a hospital each year, survival rates are less than 10 percent nationally.5 The majority of patients who do regain spontaneous circulation do not survive to hospital discharge, due to irreversible damage to the heart and brain.6 About a third of all SCA patients, however, present to first responders with VT or VF—shockable heart rhythms that can be stabilized with defibrillation.7
The underlying causes of SCA with VT or VF include coronary artery disease, which contributes to mortality in patients who initially regain circulation.8 The rate of coronary artery disease among SCA patients is over 70 percent, and total artery occlusion occurs in approximately 48 percent of these patients.8 For a population so likely to have underlying cardiac disease, physicians developing the protocol posited that these patients might be treated with greater efficacy with early access to a CCL.2,3 There, cardiac interventionists are equipped to apply primary coronary intervention, therapeutic hypothermia, and extracorporeal life support during and after resuscitation efforts while they correct the underlying causes of SCA.
The Minnesota Resuscitation Consortium (MRC) and its director, University of Minnesota Health cardiologist Demetris Yannopoulos, MD, have been leaders in the development of the protocol. Established by the University of Minnesota in an effort to expedite improved care for SCA, the MRC is a statewide network of emergency responders, hospitals, and health systems. In 2012, the MRC first established the protocol and called for resuscitated SCA patients who presented with a shockable rhythm to be transferred to a CCL within 6 hours, and ideally within 2 hours, of arrest.2 In 2015, the MRC recommended an arrest-to-transfer to CCL time of 30 minutes for patients refractory to resuscitation efforts.3
The new protocol is improving care for patients with SCA as a result of VF or VT. In patients who were initially resuscitated and transferred directly to a CCL, brain-healthy survival (Cerebral Performance Category 1 or 2) increased to 65 percent, compared to 55 percent in patients who did not enter the protocol.2 In patients who did not respond to resuscitation efforts before admission to a CCL, that number jumped from 15 percent to 42 percent.1
The protocol is now gaining national interest. A multisite, National Institutes of Health-funded clinical trial (ACCESS) launched in late 2017 will attempt to replicate the findings of an earlier Minnesota study.
Time to treatment is critical for patients with sudden cardiac arrest (SCA). SCA patients with shockable heart rhythms can experience improved outcomes under the Minnesota Resuscitation Consortium (MRC) SCA protocol. Current standard practice mandates that all SCA patients undergo emergency electrocardiogram to rule out myocardial infarction, followed by ongoing evaluation in an intensive care unit. Under the MRC protocol, SCA patients with ventricular fibrillation or ventricular tachycardia and who present within the MRC network can be transported directly to the cardiac catheterization lab (CCL) for screening and treatment for underlying heart conditions. Patients must have SCA with shockable rhythm and have received at least 3 defibrillation attempts in the field before transfer. Patients who regain circulation will undergo electrocardiogram in the emergency room, followed by treatment in the CCL within 6 hours of arrest. Patients who do not respond to defibrillation and remain under ongoing resuscitation efforts can bypass the emergency room for treatment in the CCL within 30 minutes of arrest. These approaches, pioneered by the MRC, have been shown to increase survival rates.
Minnesota Resuscitation Consortium
University of Minnesota Health cardiologists are leaders in the MRC. A partnership based at the University of Minnesota, MRC links 65 hospital systems, emergency medical services, community and educational groups and seeks to streamline care for sudden cardiac arrest patients, from increasing bystander knowledge of cardiopulmonary resuscitation to establishing statewide protocols and accelerating the delivery of care. The network includes hundreds of emergency medical services directors, first responders, cardiac interventionists, and critical care physicians and nurses, all working to improve the odds of healthy survival for patients with sudden cardiac arrest.
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To find current clinical trials available through University of Minnesota Health providers, visit studyfinder.umn.edu.
Immediate access to the cardiac catheterization lab and care team leads to complete recovery for a patient whose shockable heart rhythm was refractory to defibrillation.Continue reading