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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e786

B-type natriuretic peptide) may identify those patients with ACS at increased risk of death, HF, and recurrent MACE.19,20 Early recognition of cardiogenic shock in patients presenting with ACS on FMC by EMS or ED providers is the key to initial triage and risk stratification.21 Cardiogenic shock related to AMI is present in 7% to 10% of the ACS population and carries a high mortality rate.22 Early and rapid revascularization for cardiogenic shock related to AMI is associated with increased survival, and triage to a PCI-capable hospital and ideally to hospitals providing advanced therapies (eg, mechanical circulatory support [MCS]) is preferred (Section 8.1, “Revascularization in ACS With Cardiogenic Shock” and Section 8.2, “MCS in Patients With ACS and Cardiogenic Shock”). Several scales are available to determine the severity of shock, and observational data have shown associations between severity as assessed by these scales and outcomes.23

3.2 Management of Patients Presenting With

Cardiac Arrest Recommendations for Management of Patients Presenting With Cardiac Arrest Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 C-LD 1 Patients with cardiac arrest and STEMI who have

been resuscitated should preferentially be transferred by EMS to a PPCI-capable center.1,2

1 B-NR 2 Patients who have been resuscitated after cardiac

arrest and are noncomatose or who are comatose with favorable prognostic features and with evidence of STEMI, should undergo PPCI to improve survival.3–7

2b C-LD 3.	 In patients with cardiac arrest who are comatose,

have unfavorable prognostic features, and evidence of STEMI, PPCI may be reasonable after individualized assessment.4,7

3: No Benefit A 4 In resuscitated patients who are comatose after

cardiac arrest, electrically and hemodynamically stable, and without evidence of STEMI, immediate angiography is not recommended due to lack of benefit.8–14

Synopsis Approximately 10% of patients with STEMI transferred by EMS to the hospital are estimated to have an outof-hospital cardiac arrest.15 Early recognition of STEMI in resuscitated patients and direct transfer to a PCIcapable center is associated with improved survival.1,2 Survival-to-hospital discharge in the patient who is comatose with out-of-hospital cardiac arrest is <10% regardless of etiology.16 Those with a witnessed arrest and a shockable rhythm have improved survival. Outcomes for patients with STEMI who are awake after resuscitated cardiac arrest are comparable to patients with STEMI who were not in cardiac arrest.3 For this reason, patients with cardiac arrest who have achieved return of spontaneous circulation (ROSC) and are awake with STEMI on ECG are candidates for PPCI. However, care should be individualized in the comatose patient with rapid assessment of the patient’s clinical features and cardiac arrest characteristics before proceeding with invasive angiography.17–19 In contrast, patients who are stable without ST-segment elevation after out-of-hospital cardiac arrest do not require immediate coronary angiography. Coronary angiography can be deferred pending further risk stratification.8–13

Recommendation-Specific Supportive Text

1 Observational studies have shown an association

between triage of out-of-hospital cardiac arrest patients to a PCI-capable facility with improved outcomes.1,2,15 Data from the CARES (Cardiac Arrest Registry to Enhance Survival) registry showed that transfer to a PCI-capable center was associated with improved survival in patients with cardiac arrest and STEMI on ECG. EMS should preferentially transfer patients who are comatose after cardiac arrest, have achieved ROSC, and have STEMI on the ECG to a PPCI center.2 Although the ARREST (Advanced Reperfusion Strategies for Patients With Out of Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) trial did not show a benefit in triaging patients to primary cardiac arrest centers, this study evaluated patients without STEMI on the ECG.20

2 Nearly one-third of patients with cardiac arrest and

STEMI on ECG have normal neurologic status on presentation to the ED.3 Being alert or with partial/ minimal neurologic response on presentation with STEMI after cardiac arrest is an independent predictor of survival. Observational studies have demonstrated comparable survival of the awake patient with STEMI with cardiac arrest to those patients with STEMI without cardiac arrest.3 For this reason, patients with STEMI who have achieved ROSC and are awake should undergo PPCI (Section 5.2.1, “PPCI in STEMI”). 3.	 In patients who are comatose after cardiac arrest

and have achieved ROSC, but have STEMI on the ECG, an individualized patient assessment for survival and futility is essential before proceeding with PCI. Observational data have identified poor prognostic features that have been validated and incorporated into risk scores for this population. These include unwitnessed arrest, no bystander cardiopulmonary resuscitation, nonshockable rhythm, cardiopulmonary resuscitation >30 minutes, time to ROSC >30 minutes, arterial pH <7.2, lactate >7 mmol/L, age >85 years, and end-stage renal

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