The American Heart Association (AHA) has released a targeted update on advanced cardiovascular life support for adults. Published online on December 18 in Traffic, the update summarizes the latest findings and recommendations on medication use, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population.
A „critical“ update pertains to temperature control, noted Jon C. Rittenberger, Chairman of the Writing Group, MD, Associate Professor of Emergency Medicine at the University of Pittsburgh, Pittsburgh, Pennsylvania, in an interview with theheart.org | Medscape Cardiology. There has been a „paradigm shift“ over the years, said Rittenberger, from therapeutic hypothermia to targeted temperature management and ultimately to temperature control, based on the results of the Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial.
In the TTM2 trial involving 1900 patients with coma after out-of-hospital cardiac arrest (OHCA), targeted hypothermia at 33 °C followed by controlled rewarming did not result in a 6-month lower mortality rate compared to targeted normothermia (≥ 37.8 °C with fever treatment).
The updated temperature recommendations state that all adults who do not follow commands after return of spontaneous circulation (ROSC), regardless of the location of arrest or presenting rhythm, should receive treatment involving a conscious temperature control strategy. They recommend choosing and maintaining a constant temperature between 32°C and 37.5°C during post-arrest temperature management. „It’s important to know that temperatures in this range are appropriate,“ said Rittenberger.
The update also notes that it is „reasonable“ to maintain temperature control for at least 24 hours after achieving the target temperature. It was acknowledged that there is „insufficient“ evidence to recommend a specific therapeutic temperature for different subgroups of cardiac arrest patients. It may be prudent to actively prevent fever in patients who do not respond to verbal commands after initial temperature control.
Another „important nuance,“ according to Rittenberger, is that patients with spontaneous hypothermia after ROSC should not be routinely actively or passively warmed faster than 0.5°C per hour.
The update also addresses the timing of percutaneous coronary angiography. The previous recommendations, based on the best available data, recommended emergent coronary angiography for patients with ST-elevation myocardial infarction (STEMI) and suggested emergent angiography for selected patients (e.g., hemodynamically and electrically unstable) without ST-elevation.
The updated guidelines recommend against emergent coronary angiography in patients with ROSC after cardiac arrest as an alternative to a delayed or selective strategy unless they suffer from STEMI, shock, electrical instability, signs of significant myocardial injury, or ongoing ischemia.
The AHA has recently issued a scientific statement on modern catheter laboratory management in comatose adults with OHCA, which was published on December 19 in Traffic.
Other key takeaways from the focused update on advanced cardiovascular life support for adults include:
– Routine administration of calcium for the treatment of cardiac arrest is not recommended.
– The use of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest who do not respond to standard advanced cardiovascular life support is reasonable in selected patients when performed within an appropriately trained and equipped care system.
– In adult survivors of cardiac arrest with electroencephalographic patterns in the ictal-interictal continuum, a trial of therapy with a non-sedating antiepileptic drug may be reasonable.
– Organ donation is an important outcome to consider in the development and evaluation of care systems.
The targeted update also highlighted the importance of developing and implementing methods to improve the representation of participants from diverse backgrounds and enhance the accuracy of reporting demographic data of study participants.
„This is the first time we have actually addressed diversity, equity, and inclusion in the guidelines,“ said Rittenberger. „Many research studies do not provide good, detailed information about the type of patients they include. We are explicitly calling for this because patients with lower socioeconomic status and patients with darker skin often do worse. We want to record this and hopefully be able to develop targeted interventions for these patients.“
This research received no commercial funding, and Rittenberger has no relevant conflicts of interest.