Do not disregard the initial 12 lead ECG after out-of-hospital cardiac arrest: It predicts angiographic culprit despite metabolic abnormalities

Amit Sharma; David F Miranda; Holly Rodin; Bradley A Bart; Stephen W Smith; Gautam R Shroff

doi:10.1016/j.resplu.2020.100032

Do not disregard the initial 12 lead ECG after out-of-hospital cardiac arrest: It predicts angiographic culprit despite metabolic abnormalities

Resusc Plus. 2020 Oct 1:4:100032. doi: 10.1016/j.resplu.2020.100032. eCollection 2020 Dec.

Authors

Amit Sharma^{1

2}, David F Miranda^{1

3}, Holly Rodin⁴, Bradley A Bart^{5

6}, Stephen W Smith⁷, Gautam R Shroff⁵

Affiliations

¹ Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.
² Regions Hospital, St. Paul, MN, USA.
³ CentraCare Heart and Vascular Center, St. Cloud, MN, USA.
⁴ Analytic Center of Excellence, Hennepin Healthcare System, HCMC, Minneapolis, MN, USA.
⁵ Division of Cardiology, Department of Medicine, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA.
⁶ Veterans Affairs Medical Center, Minneapolis, MN, USA.
⁷ Emergency Department, Hennepin Healthcare System, HCMC and University of Minnesota Medical School, Minneapolis, MN, USA.

Abstract

Objectives: The initial 12 lead electrocardiogram (ECG) following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), is often disregarded by clinicians in ability to predict acute thrombotic coronary occlusion (ATCO) due to markedly abnormal metabolic milieu (AMM). We sought to evaluate the accuracy of initial vs. follow-up ECG prior to invasive coronary angiography (ICA) to predict ATCO following resuscitated OHCA.

Methods: We included OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA). AMM was defined as one of: pH < 7.1, lactate >2 mmol/L, serum potassium <2.8 or >6.0 mEq/L. Two ECGs A (initial) and B (follow-up) following ROSC but prior to ICA were adjudicated by 2 experienced readers using expanded ECG criteria to predict angiographic ATCO on ICA.

Results: 152 consecutive patients (mean age 58 years, 75% male) met inclusion criteria, 77% had AMM. Among those with both ECGs (n = 102), overall accuracy, sensitivity, specificity, positive predictive value, negative predictive value for correctly predicting angiographic ATCO for ECG A was 72%, 63%, 81%, 61%, 83% and for ECG B was 71%, 50%, 91%, 73%, 80% respectively. Predictive accuracy for angiographic ATCO was similar between ECG A [odds ratio (OR) 7.31, CI 2.87-18.62, p < 0.0001) and ECG B [OR 10.67; CI 3.6-31.61, p < 0.0001], and consistent in AMM.

Conclusions: In OHCA, despite AMM, the initial post ROSC ECG retains a statistically significant, and similar accuracy as the follow-up ECG to predict angiographic ATCO using expanded criteria.

Keywords: Coronary angiogram; Electrocardiogram; Metabolic abnormalities; Out of hospital cardiac arrest.