**2. Prevalence of CAD in patients with malignant cardiac arrhythmia**

This chapter subsumes asystole, ventricular tachycardia, ventricular storming and ventricular fibrillation under the term malignant arrhythmia.

Clinically relevant CAD with critical coronary arterial stenoses requiring PCI was shown in approximately 75% of patients with cardiac arrest [7, 8]. In the presence of an acute coronary syndrome, about 6% of these patients sustain pVT or ventricular fibrillation within the first 24 h after symptom onset [1]. There is currently no detailed information available on the exact prevalence of CAD depending on the different types of malignant arrhythmia. This is partly due to lack of representative prospective studies or registries including either preselected cohorts with smaller patient numbers and short follow-up periods. Currently running registries are:

• Incidence of SCD: approx. 1.40/100,000 person-years in women, whereas 6.68/100,000 person-years in men.

Interventional Therapies for Post-Cardiac Arrest Patients Suffering from Coronary Artery Disease

http://dx.doi.org/10.5772/intechopen.75045

45

• Active screening for cardiovascular risk factors and early detection and treatment of CAD and heart failure

• A shockable initial rhythm (VF, pVT) is associated with a higher survival rate compared to asystole and PEA.

○ Young adults: cardiac channelopathies, cardiomyopathies, myocarditis and substance abuse. ○ Older adults: degenerative heart disease such as CAD, valvular heart disease and heart failure.

• Registry of Malignant Arrhythmias and Sudden Cardiac Death – Influence of Diagnostics

Furthermore, empirical data about the influence of CAD specific therapies on the different malignant arrhythmia are inconclusive. This implies in particular the influence of coronary revascularization by PCI or aortocoronary bypass surgery (CABG), targeted catheter-based ablation of ventricular tachycardia or supply by ICD on long-term course of patients with aborted cardiac arrest. Accordingly, mortality data depending on the underlying cardiac arrhythmia in patients being treated by modern cardiological therapies are not well represented in recent studies [1]. **Table 1** summarizes the most important empirical data on CAD,

and Interventions (RACE-IT; clinicaltrials.gov identifier: NCT02982473), • Extracorporeal Life Support Organization (ELSO; https://www.elso.org).

• Parisian Region Out of Hospital Cardiac Arrest (PROCAT; [9]),

• Minnesota Resuscitation Consortium (MRC; [10]), • Resuscitation Outcomes Consortium (ROC; [11]),

• The risk of SCD is higher for men and increases with age.

• Causes:

prevents 40% of SCD cases.

• The annual death rate of SCD ranges from 1100 to 9000 in Europe.

• Structural heart disease is already known in about 50% of patients.

• The rates of asystole and PEA as initial arrhythmia in cardiac arrest are increasing.

• CAD requiring intervention is present in up to 75% of patients with survived cardiac arrest.

• Patients with persistent coma after cardiac arrest are associated with a higher mortality of up to 50%.

**Table 1.** Empirical data on coronary artery disease (CAD), malignant cardiac arrhythmia and cardiac arrest.

malignant arrhythmia and cardiac arrest.

• Emergency Cardiopulmonary Bypass (ECPB; [12, 13]),

Prior structural heart disease may be present in almost 50% of patients suffering from cardiac arrest, whereas an even higher rate of subclinical CAD is suspected in these patients. Over decades, medical research has focused on the detection of reliable risk markers for the development of malignant arrhythmia in order to reliably estimate the chance for their individual occurrence. The most robust indicator represents the degree of left ventricular (LV) dysfunction according to LV ejection fraction (LVEF). In addition, screening includes all known cardiovascular risk factors, such as increases of low-density lipoprotein (LDL) cholesterol, smoking status, presence of diabetes mellitus, arterial hypertension and obesity. The implementation of screening methods to assess patients´ individual cardiovascular risk, as well as effective diagnostics and treatment of CAD and heart failure has helped to prevent approximately 40% of SCD cases [2].

The overall rate of primary ventricular fibrillation or pulseless ventricular tachycardia (pVT) as the initial documented heart rhythm in clinical arrest settings varies between 25 and 79% in US registries in 2007, especially when occurring in public daily life [3]. In contrast, an increase of pulseless electrical activity (PEA) and asystole was documented alongside with a decrease of ventricular fibrillation and pVT. This inversion may be explained by improved medical care including improved guideline-based drug treatment for CAD and heart failure, percutaneous coronary intervention (PCI), implantable cardioverter-defibrillators (ICD), and the associated increasing prevalence of end-stage heart failure syndrome, which is associated with a higher prevalence of combined PEA or asystole at final disease stages [4, 5]. Survival rates are higher after cardiac arrest when a shockable ventricular arrhythmia (pVT or ventricular fibrillation) is documented (30.5%), whereas survival is lower in the presence of PEA or asystole (only 7.5–8%) [6].


prevalence of CAD. European guidelines estimate SCD occurring in about 1.40/100,000 personyears in women, and even higher in about 6.68/100,000 person-years in men. Accordingly, the

There are multiple varying causes for development of cardiac arrest. Structural heart diseases are present at older age, including CAD, heart valve diseases and heart failure syndrome, whereas in younger adults, cardiac arrest is more often caused by cardiomyopathies, chan-

This chapter summarizes current knowledge of patients with cardiac arrest and concomitant CAD. Current knowledge about epidemiological data on the incidence of malignant arrhythmias causing cardiac arrest depending on the presence or absence of CAD is presented. Furthermore, the potential benefits of an early coronary revascularization as well as of a prompt complete coronary revascularization compared to treatment of coronary culprit lesion only are outlined. Finally, the advantages of invasive therapies for patients surviving cardiac arrest, such as targeted temperature management and mechanical cardiac assist devices, are elucidated.

**2. Prevalence of CAD in patients with malignant cardiac arrhythmia**

This chapter subsumes asystole, ventricular tachycardia, ventricular storming and ventricular

Prior structural heart disease may be present in almost 50% of patients suffering from cardiac arrest, whereas an even higher rate of subclinical CAD is suspected in these patients. Over decades, medical research has focused on the detection of reliable risk markers for the development of malignant arrhythmia in order to reliably estimate the chance for their individual occurrence. The most robust indicator represents the degree of left ventricular (LV) dysfunction according to LV ejection fraction (LVEF). In addition, screening includes all known cardiovascular risk factors, such as increases of low-density lipoprotein (LDL) cholesterol, smoking status, presence of diabetes mellitus, arterial hypertension and obesity. The implementation of screening methods to assess patients´ individual cardiovascular risk, as well as effective diagnostics and treatment of CAD and heart failure has helped to prevent approxi-

The overall rate of primary ventricular fibrillation or pulseless ventricular tachycardia (pVT) as the initial documented heart rhythm in clinical arrest settings varies between 25 and 79% in US registries in 2007, especially when occurring in public daily life [3]. In contrast, an increase of pulseless electrical activity (PEA) and asystole was documented alongside with a decrease of ventricular fibrillation and pVT. This inversion may be explained by improved medical care including improved guideline-based drug treatment for CAD and heart failure, percutaneous coronary intervention (PCI), implantable cardioverter-defibrillators (ICD), and the associated increasing prevalence of end-stage heart failure syndrome, which is associated with a higher prevalence of combined PEA or asystole at final disease stages [4, 5]. Survival rates are higher after cardiac arrest when a shockable ventricular arrhythmia (pVT or ventricular fibrillation) is documented (30.5%), whereas survival is lower in the presence of PEA

estimated annual death rate ranges in between 1100 and 9000 in Europe [1].

nelopathies, myocarditis and substance abuse [1].

44 Myocardial Infarction

fibrillation under the term malignant arrhythmia.

mately 40% of SCD cases [2].

or asystole (only 7.5–8%) [6].


**Table 1.** Empirical data on coronary artery disease (CAD), malignant cardiac arrhythmia and cardiac arrest.

Clinically relevant CAD with critical coronary arterial stenoses requiring PCI was shown in approximately 75% of patients with cardiac arrest [7, 8]. In the presence of an acute coronary syndrome, about 6% of these patients sustain pVT or ventricular fibrillation within the first 24 h after symptom onset [1]. There is currently no detailed information available on the exact prevalence of CAD depending on the different types of malignant arrhythmia. This is partly due to lack of representative prospective studies or registries including either preselected cohorts with smaller patient numbers and short follow-up periods. Currently running registries are:


Furthermore, empirical data about the influence of CAD specific therapies on the different malignant arrhythmia are inconclusive. This implies in particular the influence of coronary revascularization by PCI or aortocoronary bypass surgery (CABG), targeted catheter-based ablation of ventricular tachycardia or supply by ICD on long-term course of patients with aborted cardiac arrest. Accordingly, mortality data depending on the underlying cardiac arrhythmia in patients being treated by modern cardiological therapies are not well represented in recent studies [1]. **Table 1** summarizes the most important empirical data on CAD, malignant arrhythmia and cardiac arrest.
