Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized,
Caroline Hauw-Berlemont1, Lionel Lamhaut2,3,4, Jean-Luc Diehl1,5
1Medical Intensive Care Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France.
Insights
For out-of-hospital cardiac arrest survivors without ST-segment elevation, emergency coronary angiography (CAG) showed no survival benefit over delayed CAG. This finding suggests current guidelines may need reassessment for this patient group.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Trials
Background:
- Emergency coronary angiography (CAG) is recommended for out-of-hospital cardiac arrest (OHCA) with ST-segment elevation.
- Its benefit in OHCA patients without ST-segment elevation remains debated.
Purpose of the Study:
- To compare 180-day survival rates with good neurological function (Cerebral Performance Category [CPC] 1 or 2) between emergency and delayed CAG in OHCA survivors without ST-segment elevation.
Main Methods:
- The EMERGE trial randomized 279 OHCA survivors without ST-segment elevation to emergency or delayed (48-96 hours) CAG.
- The primary outcome was 180-day survival with CPC 2 or less.
Main Results:
- The study was underpowered. 180-day survival rates (CPC ≤2) were 34.1% in the emergency CAG group vs 30.7% in the delayed CAG group (HR, 0.87; P=.32).
- No significant differences were observed in overall survival or secondary outcomes between groups.
Conclusions:
- Emergency CAG did not demonstrate superiority over delayed CAG for 180-day survival and neurological outcomes in OHCA survivors without ST-segment elevation.
- This suggests a potential need to re-evaluate current guidelines for this patient population.
Importance:
Although an emergency coronary angiogram (CAG) is recommended for patients who experience an out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the postresuscitation electrocardiogram (ECG), this strategy is still debated in patients without ST-segment elevation.
Objective:
To assess the 180-day survival rate with Cerebral Performance Category (CPC) 1 or 2 of patients who experience an OHCA without ST-segment elevation on ECG and undergo emergency CAG vs delayed CAG.
Design, Setting, And Participants:
The Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) trial randomly assigned survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG in 22 French centers. The trial took place from January 19, 2017, to November 23, 2020. Data were analyzed from November 24, 2020, to July 30, 2021.
Main Outcomes And Measures:
The primary outcome was the 180-day survival rate with CPC of 2 or less. The secondary end points were occurrence of shock, ventricular tachycardia, and/or fibrillation within 48 hours, change in left ventricular ejection fraction between baseline and 180 days, CPC scale at intensive care unit discharge and day 90, survival rate, and hospital length of stay.
Results:
A total of 279 patients (mean [SD] age, 64.7 [14.6] years; 195 men [69.9%]) were enrolled, with 141 (50.5%) in the emergency CAG group and 138 (49.5%) in the delayed CAG group. The study was underpowered. The mean (SD) time delay between randomization and CAG was 0.6 (3.7) hours in the emergency CAG group and 55.1 (37.2) hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (hazard ratio [HR], 0.87; 95% CI, 0.65-1.15; P = .32). There was no difference in the overall survival rate at 180 days (emergency CAG, 36.2% [51 of 141] vs delayed CAG, 33.3% [46 of 138]; HR, 0.86; 95% CI, 0.64-1.15; P = .31) and in secondary outcomes between the 2 groups.
Conclusions And Relevance:
In this randomized clinical trial, for patients who experience an OHCA without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequelae.
Trial Registration:
ClinicalTrials.gov Identifier: NCT02876458.
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