As per ESC 2018 guidelines, consider obtaining urgent angiography, and performing PCI if indicated, in patients with resuscitated cardiac arrest without diagnostic ST-segment elevation but with a high suspicion of ongoing myocardial ischemia. C Show 2 more As per AHA/ACC 2013 guidelines, obtain immediate coronary angiography and perform primary PCI in patients with out-of-hospital cardiac arrest after resuscitation, if the initial ECG shows STEMI. B Post-resuscitation evaluation (provocation tests): Obtain sodium channel blocker testing and exercise testing in sudden cardiac arrest survivors without a clear underlying cause. B Consider obtaining ergonovine, acetylcholine, or hyperventilation testing for the diagnosis of coronary vasospasm in sudden cardiac arrest survivors. C Post-resuscitation evaluation, genetic testing: As per ESC 2022 guidelines, obtain genetic testing in patients survived sudden cardiac arrest due to ventricular arrhythmia. B As per HRS/ACC/AHA 2018 guidelines: Obtain further evaluation for genetic arrhythmia syndromes in young patients (aged < 40 years) with unexplained sudden cardiac arrest, unexplained near-drowning, or recurrent exertional syncope in the absence of ischemic or other structural heart diseases. B Consider offering genetic counseling in patients and family members requiring genetic testing for risk stratification for sudden cardiac arrest or sudden cardiac death. B Post-resuscitation evaluation (evaluation for extra-cardiac causes): evaluate sudden cardiac arrest survivors without obvious extra-cardiac causes by a multidisciplinary team. B Show 2 more Neuroprognostication (general principles): ensure a multimodal approach for neuroprognostication based on a combination of findings (rather than a single finding) in patients remaining comatose after cardiac arrest. B Show 3 more Neuroprognostication (clinical evaluation): Consider assessing the following at 72 hours after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose: bilaterally absent of pupillary light reflex bilaterally absent of corneal reflexes https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 15/24 6/29/23, 3:44 AM Cardiac arrest Pathway quantitative pupillometry status myoclonus. C Show 3 more Neuroprognostication (laboratory evaluation): Consider assessing for high serum values of NSE within 72 hours after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose. C Insufficient evidence regarding the usefulness of S100 calcium-binding protein, Tau, neurofilament light chain, and GFAP for neuroprognostication. I Neuroprognostication (electroencephalography): insufficient evidence regarding the prognostic value of seizures when evaluated with other prognostic tests in patients remaining comatose after cardiac arrest. I Show 3 more Neuroprognostication (neuroimaging): Consider assessing for reduced gray-white ratio on brain CT after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose. C Consider assessing for extensive areas of restricted diffusion and reduced apparent diffusion coefficient on brain MRI at 2-7 days after cardiac arrest, in combination with other prognostic tests, to support the prognosis of poor neurological outcome in patients remaining comatose. C Recovery and survivorship: obtain structured assessment for anxiety, depression, posttraumatic stress, and fatigue in cardiac arrest survivors and their caregivers. B Show 3 more Post-cardiac arrest ICD implantation (ischemic heart disease): perform ICD placement in patients with ischemic heart disease survived sudden cardiac arrest due to VT/VF, B if the expected meaningful survival is > 1 year. B Post-cardiac arrest ICD implantation, coronary artery spasm: As per ESC 2022 guidelines, consider performing ICD placement in sudden cardiac arrest survivors with coronary artery spasm. C As per HRS/ACC/AHA 2018 guidelines: Consider performing ICD placement in patients resuscitated from sudden cardiac arrest due to coronary artery spasm, if medical therapy is ineffective or not tolerated and the meaningful survival is > 1 year. C Consider performing ICD placement in addition to medical therapy in patients resuscitated from sudden cardiac arrest due to coronary artery spasm, if the expected meaningful survival is > 1 year. C Post-cardiac arrest ICD implantation, cardiomyopathies: As per ESC 2022 guidelines, perform ICD placement in patients with dilated cardiomyopathy survived sudden cardiac arrest due to VT/VF or experienced hemodynamically not-tolerated sustained monomorphic VT. B https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 16/24 6/29/23, 3:44 AM Cardiac arrest Pathway As per ACC/AHA 2020 guidelines, perform ICD placement in patients with hypertrophic cardiomyopathy and previous documented cardiac arrest or sustained VT. B As per HRS 2019 guidelines, perform ICD placement in patients with cardiac amyloidosis survived a cardiac arrest, if the expected meaningful survival is > 1 year. B As per HRS/ACC/AHA 2018 guidelines, perform ICD placement in patients with non-ischemic cardiomyopathy survived sudden cardiac arrest due to VT/VF, B if the expected meaningful survival is > 1 year. B Show 4 more Post-cardiac arrest ICD implantation, Brugada syndrome: As per HRS/ACC/AHA 2018 guidelines, perform ICD in patients with Brugada syndrome with spontaneous type 1 Brugada ECG pattern survived cardiac arrest, sustained ventricular arrhythmia, or with a recent history of syncope presumed due to ventricular arrhythmia, if the expected meaningful survival is > 1 year. B As per APHRS/EHRA/HRS 2013 guidelines, perform ICD placement in patients with Brugada syndrome survived a cardiac arrest, or with a documented spontaneous sustained VT with or without syncope. A Post-cardiac arrest ICD implantation (short QT syndrome): Perform ICD placement in patients with short QT syndrome survived cardiac arrest or sustained ventricular arrhythmia, if the expected meaningful survival is > 1 year. B Consider performing ICD placement in patients with a cardiac channelopathy survived sudden cardiac arrest, if the expected meaningful survival is > 1 year. B Post-cardiac arrest ICD implantation, early repolarization pattern: As per HRS/ACC/AHA 2018 guidelines, perform ICD placement in patients with an early repolarization pattern on ECG and cardiac arrest or sustained ventricular arrhythmia, if the expected meaningful survival is> 1 year. B As per ESC 2018 guidelines, consider performing ICD implantation in patients with an early repolarization pattern and suspected arrhythmic syncope in the presence of a family history of early repolarization pattern with cardiac arrest. C Post-cardiac arrest ICD implantation (adult congenital heart disease): perform ICD placement in patients with adult congenital heart disease after sudden cardiac arrest due to VT or VF in the absence of reversible causes, if the expected meaningful survival is > 1 year. B Post-cardiac arrest ICD implantation (idiopathic VT/VF): perform ICD placement in patients resuscitated from sudden cardiac arrest due to idiopathic polymorphic VT or VF, if the expected meaningful survival is > 1 year. B 9. Quality improvement Public access defibrillation: https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 17/24 6/29/23, 3:44 AM Cardiac arrest Pathway Ensure public access defibrillation is available at sites where cardiac arrest is more likely to occur. B Promote community training in basic life support to increase bystander CPR rate and automated external defibrillator use. B Clinical findings Symptoms Past medical history Fainting Arrhythmogenic RV cardiomyopathy Loss of consciousness Brugada syndrome Past events CKD Cardiac amyloidosis Blunt chest trauma Cardiac sarcoidosis Drowning Catecholaminergic polymorphic VT Lightning Congenital heart disease Social history Coronary artery disease Cocaine use Diabetes mellitus Opioids use Dilated cardiomyopathy Tobacco use Dyslipidemia HF Vascular exam Hypertension Hypertrophic cardiomyopathy Absence of pulse LV noncompaction Respiratory exam Long QT syndrome Myocardial infarction Apnea Myocarditis Obesity Lab findings Obstructive sleep apnea Hyperkalemia PE Hypocalcemia Short QT syndrome Hypokalemia Substance use disorder Hypomagnesemia Takotsubo cardiomyopathy VHD Imaging findings WPW syndrome Cardiac standstill Medication history Antiarrhythmics Antidepressants Digoxin Opioids https://web.pathway.md/diseases/recY9C9KT1dKiqMcI 18/24 6/29/23, 3:44 AM Cardiac arrest Pathway Vital signs Hypotension Cardiac exam Absence of heartbeat Integument exam Cyanosis Pallor ECG findings Asystole Early repolarization VF VT Ventricular arrhythmia Studies 2023 HYBRID II In patients aged 20-80 years with coma following cardiogenic out-of-hospital cardiac arrest, hydrogen gas were not superior to control with respect to cerebral performance category of 1 or 2 at day 90. Tomoyoshi Tamura et al. EClinicalMedicine. 2023 Mar 17. 2022 BOX In comatose adults who had been resuscitated after an out-of-hospital cardiac arrest of presumed cardiac cause, high BP target was not superior to low BP target with respect to death from any cause or hospital discharge with a Cerebral Performance Category of 3 or 4 at day 90. Jesper Kjaergaard et al. N Engl J Med. 2022 Oct 20. Show 16 more References 1. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 2. 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