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Coronary Angiography After Cardiac Arrest Without ST Segment Elevation: One-Year Outcomes of the COACT Randomized
Jorrit S Lemkes1, Gladys N Janssens1, Nina W van der Hoeven1
1Department of Cardiology, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands.
Insights
Immediate coronary angiography is not superior to delayed angiography for cardiac arrest survivors without ST-elevation myocardial infarction. Delaying angiography until after neurologic recovery does not negatively impact 1-year clinical outcomes.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Trials
Background:
- Ischemic heart disease frequently causes cardiac arrest.
- Limited randomized data exist on long-term outcomes for immediate coronary angiography in cardiac arrest survivors without ST-elevation myocardial infarction (STEMI).
Purpose of the Study:
- To compare clinical outcomes at 1 year between immediate and delayed coronary angiography strategies in cardiac arrest survivors without STEMI.
Main Methods:
- A multicenter, open-label, randomized trial involving 552 patients resuscitated from out-of-hospital cardiac arrest without STEMI.
- Patients were randomized to immediate or delayed coronary angiography (if indicated) and followed for 1 year.
Main Results:
- No significant differences in survival or the composite endpoint of death, myocardial infarction, or revascularization were observed at 1 year between the immediate and delayed angiography groups.
- Rates of implantable cardioverter-defibrillator shocks and other assessed outcomes were also similar between the groups.
Conclusions:
- Immediate coronary angiography is not superior to a delayed strategy in patients resuscitated from cardiac arrest without STEMI.
- Coronary angiography can be safely delayed until after neurologic recovery in this patient population without adversely affecting clinical outcomes.
Importance:
Ischemic heart disease is a common cause of cardiac arrest. However, randomized data on long-term clinical outcomes of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients successfully resuscitated from cardiac arrest in the absence of ST segment elevation myocardial infarction (STEMI) are lacking.
Objective:
To determine whether immediate coronary angiography improves clinical outcomes at 1 year in patients after cardiac arrest without signs of STEMI, compared with a delayed coronary angiography strategy.
Design, Setting, And Participants:
A prespecified analysis of a multicenter, open-label, randomized clinical trial evaluated 552 patients who were enrolled in 19 Dutch centers between January 8, 2015, and July 17, 2018. The study included patients who experienced out-of-hospital cardiac arrest with a shockable rhythm who were successfully resuscitated without signs of STEMI. Follow-up was performed at 1 year. Data were analyzed, using the intention-to-treat principle, between August 29 and October 10, 2019.
Interventions:
Immediate coronary angiography and PCI if indicated or coronary angiography and PCI if indicated, delayed until after neurologic recovery.
Main Outcomes And Measures:
Survival, myocardial infarction, revascularization, implantable cardiac defibrillator shock, quality of life, hospitalization for heart failure, and the composite of death or myocardial infarction or revascularization after 1 year.
Results:
At 1 year, data on 522 of 552 patients (94.6%) were available for analysis. Of these patients, 413 were men (79.1%); mean (SD) age was 65.4 (12.3) years. A total of 162 of 264 patients (61.4%) in the immediate angiography group and 165 of 258 patients (64.0%) in the delayed angiography group were alive (odds ratio, 0.90; 95% CI, 0.63-1.28). The composite end point of death, myocardial infarction, or repeated revascularization since the index hospitalization was met in 112 patients (42.9%) in the immediate group and 104 patients (40.6%) in the delayed group (odds ratio, 1.10; 95% CI, 0.77-1.56). No significant differences between the groups were observed for the other outcomes at 1-year follow-up. For example, the rate of ICD shocks was 20.4% in the immediate group and 16.2% in the delayed group (odds ratio, 1.32; 95% CI, 0.66-2.64).
Conclusions And Relevance:
In this trial of patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, a strategy of immediate angiography was not found to be superior to a strategy of delayed angiography with respect to clinical outcomes at 1 year. Coronary angiography in this patient group can therefore be delayed until after neurologic recovery without affecting outcomes.
Trial Registration:
trialregister.nl Identifier: NTR4973.
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