Immediate angiography not better than delayed angiography in non-STEMI cardiac arrest patients

Recent data from the COACT trial shows there may be no survival advantage when immediate coronary angiography is performed compared with delayed angiography in patients who have been successfully resuscitated after out-of-hospital cardiac arrest and who had no signs of ST-segment elevation myocardial infarction (STEMI) [1].

The Dutch multicentre COACT trial randomised 552 patients with cardiac arrest without signs of STEMI who were to undergo immediate coronary angiography (n=273) or delayed coronary angiography until after neurologic recovery (n=265). All participants underwent percutaneous coronary intervention if indicated. The primary endpoint of the trial was survival at 90 days; secondary endpoints included survival at 90 days with good cerebral performance or mild or moderate disability, myocardial injury, duration of catecholamine support, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, major bleeding, occurrence of acute kidney injury, need for renal-replacement therapy, time-to-target temperature, and neurologic status at discharge from the intensive care unit.

The survival rate at 90 days of patients in the immediate angiography group was 65.4%; for the delayed angiography group this was 67.2% (OR 0.89; 95% CI, 0.62-1.27; P=0.51). The median time to target temperature in the immediate angiography group was 5.4 hours vs 4.7 hours in the delayed angiography group (ratio of geometric means, 1.19; 95% CI, 1.04-1.36). Furthermore, no significant differences were observed between both groups with regard to the other secondary endpoints. These findings led to the conclusion that routine immediate angiography in this particular population does not seem to be necessary. Instead, target-temperature management seems more important. However, researchers emphasised that this is a very specific population (e.g. patients with STEMI or signs of posterior-wall infarction were excluded), which should always be considered when assessing patients for one strategy or the other. Also, an important limitation of this study is that <20% of patients enrolled in the COACT trial suffered from acute unstable coronary lesions at angiography; thus, most patients in cardiac arrest undergoing angiography did not have clinically significant coronary lesions. This means, according to the researchers, that timing of coronary angiography (or the performance of coronary angiography in itself) may positively affect a very small proportion of the trial population only.

1. Lemkes J, et al. Abstract 410-10. ACC 2019, 16-18 March, New Orleans, USA.



Posted on 6 June 201928 March 2024