Dokončna tromboza žilne opornice pri nezavestnih bolnikih po zastoju srca izven bolnišnice zdravljenih s perkutanim koronarnim posegom in terapevtsko hipotermijo

Rauber, Martin (author), Noč, Marko (mentor)

Izhodišča: Glede na podatke objavljene v retrospektivnih raziskavah pogostnost tromboze žilne opornice (ST), pri nezavestnih bolnikih po zastoju srca izven bolnišnice (OHCA), zdravljenih s perkutanim koronarnim posegom (PCI) in terapevtsko hipotermijo (TH), močno variira, med 2,7% in 31%. Namen in hipoteza: Želeli smo prospektivno oceniti pogostnost, časovno pojavnost in napovedne dejavnike za pojav ST ter njen vpliv na prognozo teh bolnikov. Dodatno smo domnevali, da je prava pogostnost dokončne ST večja, kot pogostnost dokončne ST, ki se potrdi le na podlagi kliničnega suma s koronarografijo (CAG) ali kasneje z obdukcijo. Metode: V prospektivno raziskavo smo vključili zaporedne nezavestne bolnike, med avgustom 2016 in julijem 2021, po primarnem OHCA, ki so bili zdravljeni s takojšnjo PCI in DES ter TH (32-34°C). Pri kliničnem sumu na ST, v odsotnosti tega pa programsko med 8-12 dnem po OHCA, smo opravili ponovno koronarografijo. Pri vseh umrlih smo opravili obdukcijo in histopatološko analizo stentiranih predelov. Rezultati: Med 362 nezavestnimi bolniki po OHCA je bila takojšnja CAG s PCI opravljena pri 169 bolnikih (47%). Končno število vljučenih bolnikov v analizo ST je bilo 151, saj pri 18 bolnikih spremljanja nismo mogli dokončati. Dokončna ST je bila potrjena pri 29 bolnikih (19.2%; 95% interval zaupanja: 12.9%-25.6%), od tega s CAG pri 18 ali obdukcijo pri 11 bolnikih. Pri 59% bolnikov je do ST prišlo v prvih 3 dneh po OHCA. Pri 79% bolnikov je imela ST vsaj en klinični znak. 17% bolnikov s ST in 60% brez ST je imelo dober nevrološki izzid ob odpustu (p<0.001). Neodvisni napovedni dejavniki za ST so bili: daljši čas oživljanja na terenu, nižji arterijski pH in višje vrednosti kretinina ob sprejemu. Z našim protokolom za sistematično iskanje in ugotavljanje ST smo potrdili signifikantno višje število ST, kot bi jih potrdili le na podlagi kliničnega suma. Zaključki: Pogostnost dokončne ST pri nezavestnih bolnikih po OHCA zdravljenih s PCI in TH je visoka (19.2%) in po literaturi pomembno višja, kot pri drugih skupinah bolnikov po PCI, kljub uporabi najnovejših DES in uporabi antikoagulantne/antiagregacijske terapije. Pomembno število ST je klinično nemih.

• Language: Slovenian
• Keywords: z zdravili prevlečena žilna opornica, izvenbolnišnični srčni zastoj, tromboza žilne opornice
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2023
• PID: 20.500.12556/RUL-145140
• COBISS.SI-ID: 151920643
• Publication date in RUL: 08.04.2023

Secondary language

• Language: English
• Title: Definite stent thrombosis in comatose out of hospital cardiac arrest survivors treated with percutaneous coronary intervention and mild therapeutic hypothermia

Abstract

Background: Incidence of stent thrombosis (ST) in comatose survivors of out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI) and therapeutic hypothermia (TH) varies considerably, from 2.7% to 31.2% in previously published retrospective studies. Aims and hypothesis: We aimed to prospectively investigate occurrence, timing, predictors and prognostic impact of definite ST. Additionally we hypothesised that the incidence of true definite ST in these patients is greater than the ST incidence confirmed only on the basis of clinical suspicion by coronary angiography (CAG) or later with autopsy. Methods: We prospectively investigated consecutive comatose survivors of OHCA with presumed cardiac aetiology undergoing immediate PCI with drug-eluting stents (DES) and TH targeted at 3P admitted between August 2016 and July 2021. Repeat CAG was performed if ST was suspected and systematically between day 8-12 in the absence of clinical signs. All deceased patients underwent autopsy and histopathological analysis. Results: Among 362 comatose survivors of OHCA, immediate PCI with stenting was performed in 169 patients (47%). Since 18 patients did not complete follow-up, 151 patients were ultimately enrolled in ST analysis. Definite ST was confirmed in 29 patients (19.2%; 95% confidence interval [CI]: 12.9%-25.6%) either by CAG (n=18) or autopsy (n=11). ST occurred within 3 days in 59% and presented with at least one clinical sign in 79%. Survival with good neurological recovery was observed in 17% of patients with ST and in 60% of patients without ST (p<0.001). Independent predictors of ST were longer prehospital resuscitation, lower arterial pH and increased creatinine on admission. Protocol guided definite ST assessment identified significantly higher number of definite ST compared to just clinically driven ST assessment. Conclusions: The incidence of definite ST in comatose survivors of OHCA undergoing immediate PCI and TH targeted at 32-34°C is substantial (19.2%) and significantly higher than in other PCI subsets despite systematic use of contemporary DES and anticoagulation/antiplatelet treatment. A substantial amount of definite ST is clinically silent.

• Keywords: drug-eluting stent, out-of-hospital cardiac arrest, stent thrombosis