Written by Michael Stocker
Spoon Feed
Out-of-hospital cardiac arrest (OHCA) patients with prehospital post-ROSC (return of spontaneous circulation) STEMI on ECG often don’t have STEMI on ECG in the ED.
Post-ROSC STEMI, there and gone again
Timely STEMI care is of paramount importance in the emergency care setting. While STEMI accounts for a significant portion of OHCAs, and clear STEMI on ECG in the ED post-ROSC warrants cath-lab activation, a recent study found that two-thirds of patients with out-of-hospital (OOH) post-ROSC ECGs meeting STEMI criteria did not meet STEMI criteria on repeat ECG in the ED.
Today’s article is a secondary analysis of that study looking at factors associated with resolution of STEMI criteria from OOH ECG to ED ECG in adult patients presenting to EMS as OHCA and achieving ROSC prior to ED arrival. The original study included 176 patients, 49 of which had OOH ECGs that met STEMI criteria, with 33 of those 49 (67%) not meeting STEMI criteria on ED ECG. Factors associated with resolution of STEMI criteria included shorter time to ROSC, lower epinephrine exposure, lower incidence of norepinephrine exposure, shorter interval between ROSC and OOH ECG, and greater interval between OOH ECG to ED ECG. As with any secondary analysis, the findings are limited by the original study, which in this case was a retrospective case series with a small sample size.
How will this change my practice?
I’m still activating a STEMI alert if an EMS crew transmits a post-ROSC ECG meeting STEMI criteria. But I think the important message here is to avoid allowing diagnostic momentum to lead to premature closure. Get serial ECGs, and keep the OHCA differential broad, whether you’re in EMS or the ED.
Another Spoonful
We’re excited to have a comment from the study’s lead author, Christopher Naas:
“Ischemic ECG findings in the immediate post-ROSC period may be highly susceptible to change, and both EMS and ED clinicians should obtain serial ECS as they determine patient disposition. There may be consideration for delaying the immediacy of OOH ECG acquisition post-ROSC in favor of other interventions and transport.”
Source
Associations with resolution of ST-segment elevation myocardial infarction criteria on out-of-hospital 12-lead electrocardiograms following resuscitation from cardiac arrest. Resuscitation. 2025 Apr;209:110567. doi: 10.1016/j.resuscitation.2025.110567. Epub 2025 Mar 6. PMID: 40057016
