Below brief reference review for the lecture recently delivered at the ICEM 2025 conference on ‘ROSC: NOW WHAT?”
I will soon (Mid July) be posting a more extensive reference review as well as a recording of the ROSC lecture being given at EMCORE London 2025, as well as an extended post.
We know that survival from out of hospital cardiac arrest is poor- somewhere between 6 and 10%, if they receive good cardiopulmonary resuscitation. Less than 50% of these patients are neurologically intact at 6 months.
Post cardiac arrest brain injury is the main cause of death and of poor neurological outcome and long term disability in patients resuscitated following out of hospital cardiac arrest. The pathophysiology involves primary ischaemic injury(which occurs during cardiac arrest and resuscitation) and secondary reperfusion injury, which occurs in the post ROSC period.
Poor outcomes are associated with post cardiac arrest syndrome which occurs due to ischaemia and reperfusion injury and results in:
- myocardial dysfunction
- hypoxaemic ischaemic brain injury which is
References
- Nielsen N, et al. Targeted temperature management at 33◦ C versus 36◦ C after cardiac arrest. N Engl J Med 2013;369:2197–206.)Spaulding CM, et al. Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. NEJM 1997;336:1629–33.
- Sundgreen C, Larsen FS, Herzog TM, Knudsen GM, Boesgaard S, Aldershvile J. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke 2001;32:128–32
- Ameloot K, et al. An observational near-infrared spectroscopy study on cerebral autoregulation in post-cardiac arrest patients: time to drop “one-size-fits-all” hemodynamic targets? Resuscitation 90:121–126
- Sekhon MS, et al. The burden of brain hypoxia and optimal mean arterial pressure in patients with hypoxic ischemic brain injury after cardiac arrest. Crit Care Med 47:960–969
- Niemela V, et al. Higher versus lower blood pressure targets after cardiac arrest: systematic review with individual patient data meta-analysis. Resuscitation. 2023;189, 109862. https://doi.org/10.1016/j.resuscitation.2023.109862
- Ameloot K, et al. Early goal-directed haemodynamic optimization of cerebral oxygenation in comatose survivors after cardiac arrest: the Neuroprotect post-cardiac arrest trial. Eur Heart J. 2019;40:1804–1814. https://doi.org/10.1093/eurheartj/ehz120.
- Grand J, et al. A randomised double-blind pilot trial comparing a mean arterial pressure target of 65 mm Hg versus 72 mm Hg after out- of-hospital cardiac arrest. Eur Heart J Acute Cardiovasc Care. 2020;9:S100–S109. https://doi.org/10.1177/2048872619900095.
- Jakkula P, et al. COMACARE study group. Targeting low- normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial. Intensive Care Med. 2018;44:2091–2101. https://doi.org/10.1007/s00134-018-5446-8.
- Kjaergaard J, et al. Blood-pressure targets in comatose survivors of cardiac arrest. N Engl J Med. 2022;387:1456–1466. https://doi.org/10.1056/NEJMoa2208687.
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- Lacocqne J. Pre-hospital post ROSC blood pressure and associated neurological outcome. Am J Emerg Med 2021;49:195-199
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- Kjaergaard J et al. Blood-Pressure Targets in Comatose Survivors of Cardiac Arrest. NEJM 387;16 2022 pp 1456-1466
- Baldi E., et al. Association of Timing of Electrocardiogram Acquisition After Return of Spontaneous Circulation With Coronary Angiography Findings in Patients With Out-of-Hospital Cardiac Arrest. JAMA Network Open. 2021;4(1):e2032875.doi:10.1001/jamanetworkopen.2020.32875
- Lemkes, J.J et al. Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. NEJM April 11,2019, 380;15: pp 1397-1407.
- Desch S., et al. Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. NEJM. Dec 2021. 385;27: 2544-2553.
- Nielsen N et al. TTM Trial Investigators. Targeted temperature management at 33 C after cardiac arrest. NEJM 2013;369:2197
- Cooper PJ et al. Concordance of brain and core temperature in comatose patients after cardiac arrest. There Hypothermic Temp Management 2016; 6:194-7
- Johnsson J et al. Functional outcomes associated with varying bench of targetted temperature managementafter out of hospital cardiac arrest- an INTCAR2 Registry Analysis. Resuscitation 2019
- Noc M, et al. Invasive coronary treatment strategies for out-of-hospital cardiac arrest: a consensus statement from the European Association for Percutaneous Cardiovascular Interventions (EAPCI)/Stent for Life (SFL) groups. EuroIntervention: J EuroPCR Collaboration Working Group Interventional Cardiol Europ Soc Cardiol 2014;10:31–7.
- Kern KB, et al. Outcomes of comatose cardiac arrest survivors with and without ST-segment elevation myocardial infarction: importance of coronary angiography. JACC Cardiovascular Interventions 2015;8:1031–40.
