PCI and hypothermia for

STEMI in a patient found

and resuscitated in a
hospital elevator

Kristina Maric Besic, MD

Department of Cardiovascular Medicine
School of Medicine & University Hospital Centre
Zagreb
Zagreb, Croatia
 Disclosure Statement of Financial Interest

I, Kristina Maric Besic DO NOT have a

financial interest/arrangement or affiliation
with one or more organizations that could
be perceived as a real or apparent conflict
of interest in the context of the subject of
this presentation.
CASE REPORT:

•March 2010 - male, 45 years, no history or

known risk factors for CVD
•Unwitnessed cardiac arrest in a hospital
elevator (found at aprox. 7:20 p.m)
•CPR in ER: adrenalin 3 mg, DCx4 for VF
•ECG:sinus rhythm, anterolateral STEMI
•Admitted to CCU (around 8:00 p.m) RR 90/60
mmHG, without spontaneus breathing, coma
–GCS 3
• Urgent coronary angiography and PPCI
without prior neurological examination
• Hypothermia after PCI
• NG tube – retention 500 ml- did not recieve
aspirin or clopidogrel befor PCI
• Unfractioned heparin during PCI
• Coronary angiography finding- occlusion
of prox. LAD, significant stenosis of LCX
and RCA
• Perforation of coronary artery -
call the surgeon?
PCI PROCEDURE

•Started 8:55 p.m, ended 10:52 p.m.

•Resuscitated – adrenalin, atropin
•LAD – 5 stents - TIMI 3
•RCA – 2 stents – TIMI 3
ANTITHROMBOTIC THERAPY

•15 000 IU unfractioned heparin during PCI

•Continuous iv unfractioned heparin after
PCI- was not given because of prolonged
APTT
• ECHO- no pericardial effusion
• Neurological examination – pupils no light
response, corneal reflex and MTR absent
• Hypothermia (induced at 1:15 a.m)
• Midazolam, rocuronium (sedation and
neuromuscular blockade)
• Cooling induction with cold saline 4ºC
(30ml/kg during 30-60 min) and “ice
packages” (neck, armpits, groins) – target
body temperature 32-34ºC during 2-6 h
• At 5:30 a.m RR ↓ 90/60 mmHg - dopamine
• At 7:30 a.m RR ↓70/50 mmHg - dobutamine
and noradrenaline
• ↓ Hgb (132-126-120-97g/L), normal platlet
count, APTT >120, >150 s (24.0-33.0)
• X ray- left pleural effusion
• At 2:20 p.m VT, VF, - CPR, urgent
evacuation of pleural effusion – 1500 ml of
blood- autotransfusion
• Death at 3:45 p.m – hemorrhagic shock
2005 AHA Guidelines for Cardiopulmonary
Resuscitation and Emergency
Cardiovascular Care:

•Unconscious patients with ROSC after out-

of-hospital cardiac arrest should be cooled to
32°C to 34°C for 12-24 hours when the inital
rhytm was VF (Class IIa)
•May be beneficial for patients with non-VF
arrest out of hospital or for in-hospital arrest
(Class IIb)
HYPOTHERMIA INDICATIONS
•Cardiorespiratory arrest (VT,VF, PEA,
asystolia)
•Duration of cardiorespiratory arrest 5-15
min (from the beginning until CPR)
•Duration to spontaneous circulation ≤ 60
min
•Coma, GCS <9 – no adequate response after
spontaneous circulation- call the neurologist
•Mehanical ventilation
HYPOTERMIA CONTRAINDICATIONS
•Haemodinamic instability
•Recurrent or refractory VF or VT
•Haemorrhage
•Refractory hypoxia
•Other: unwitnessed arrest, coma of other
etiology, head trauma, operation before 14
days, terminal illnes, pregnancy, sepsis,
burns, sickle cell anemia
HYPOTERMIA RELATIVE
CONTRAINDICATIONS

•Coagulopathy: INR > 2, trc < 50 000, APTT

> 65, cryoglobulinaemia, Raynaud sy

Hypothermia is not contraindicated in PCI

and thrombolysis for AMI
DILEMMAS
• Should all or selected cardiac arrest
patients undergo PPCI ? - unwitnessed
cardiac arrest (poor predictor of survival)
• PCI before or after neurological
examination? - waist of time?
• Hypothermia before or after PCI?
• Antiplatlet and antithrombotic therapy, GP
IIb/IIIa in prolonged CPR and hypothermia?
THINK ABOUT
•Complications after prolonged CPR are not
rare (sternal or rib fractures, hematothorax,
pneumothorax.....)
•Hypothermia and bleeding complications
(coagulopathy- platlet count, platlet function,
kinetics of clotting enzymes and
plasminogen activator inhibitors...)
•Other hypothermia complications-
arrhythmias, sepsis, hyperglycemia...
TREATMENT OPTIONS
•ECMO (ExtraCorporeal Membrane
Oxygenation) in cardiac arrest
•Protocol–CPR, ECMO, IABP, PPCI,
hypothermia
•New studies-CHEER (refractory out of
hospital cardiac arrest treated with mehanical
CPR, Hypothermia, ECMO and Early
Reperfusion)
•New guidelines 2010
Thank you for your attention