How Much Is Enough

Optimal care for the fortunate few resuscitated after out-of-hospital cardiac arrest remains uncertain. An aggressive approach to simultaneously cool and cath such patients on arrival at the hospital is favored by some interventional cardiologists.1–11 Others remain unconvinced that such therapy is beneficial or needed.12–14See Article by Waldo et al See Article by Geri et al See Article by Vyas et al See Article by Staer-Jensen et al In this issue of Circulation: Cardiovascular Interventions are 4 reports regarding immediate coronary angiography and its role in postresuscitation care.15–18Vyas et al report on 4029 postcardiac arrest patients from the Cardiac Arrest Registry to Enhance Survival (CARES) database between January 2010 and December 2013.15 CARES is a large national prospective emergency medical systems-based registry involving over 800 emergency medical service agencies in 21 states with a catchment area of over 80 million people. The emphasis of this registry has been in-field cardiac arrest and resuscitation variables, but some postresuscitation variables were added in 2010 as optional data elements, including data on the performance of coronary angiography post arrest. A small number of patients treated at hospitals without cardiac catheterization facilities were excluded. The final study population consisted of 4029 out-of-hospital cardiac arrest patients resuscitated from an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia and admitted to 374 hospitals in the United States. This is the largest cohort published to date which examines the association of coronary angiography post arrest and survival. Nearly half (48.5%) underwent early coronary angiography, as directed by the attending cardiologist’s preference, though no other information was provided about the decision for or against angiography. Because the database concentrates on resuscitation variables, information about the postresuscitation electrocardiographic presence of ST-segment–elevation was not available on about half …