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Immediate angiography fails to improve survival after cardiac arrest without STEMI
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NEW ORLEANS — Among patients revived from out-of-hospital cardiac arrest who had ischemic heart disease but not STEMI, there was no difference in 90-day survival or myocardial injury between immediate and delayed angiography, according to the results of the COACT trial.
The researchers randomly assigned 552 patients who were resuscitated from cardiac arrest without any signs of STEMI to undergo coronary angiography immediately (mean age, 66 years; 82% men) or to have it delayed until after neurologic recovery (mean age, 65 years; 76% men). Jorrit S. Lemkes, MD, interventional cardiologist at Amsterdam University Medical Center, presented the findings, which were also published in The New England Journal of Medicine, at the American College of Cardiology Scientific Session.
“The guidelines recommend immediate coronary angiography in patients who present with cardiac arrest and STEMI; this is a class I recommendation,” Lemkes said during his presentation. “In patients with cardiac arrest without ST-elevation, the guidelines also recommend emergency angiography, but it is a weak recommendation with very low-quality evidence. This is based on observational data, and no randomized trials had been performed until now.”
No survival difference
The primary endpoint of 90-day survival was met by 64.5% of patients in the immediate group and 67.2% in the delayed group (OR = 0.89; 95% CI, 0.62-1.27), according to the researchers.
Median time to target temperature was longer in the immediate group (5.4 hours vs. 4.7 hours; ratio of geometric means = 1.19; 95% CI, 1.04-1.36), Lemkes said.
There were no differences between the groups in any other secondary endpoints, including survival at 90 days with good cerebral performance or mild/moderate disability, myocardial injury, duration of catecholamine support, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, major bleeding, acute kidney injury, need for renal replacement therapy and neurologic status at ICU discharge.
Angiography was performed in 97.1% of the immediate group and 64.9% of the delayed group. In the immediate group, 33% had PCI, 6.2% had CABG and 61.5% had medical or conservative therapy, whereas in the delayed group, 24.2% had PCI, 8.7% had CABG and 67.5% had medical or conservative therapy. In the delayed group, 38 patients received immediate therapy because of cardiac deterioration, according to the researchers.
Lemkes said there were interactions by age and history of CAD. Patients younger than 70 years had better results with delayed angiography, but patients aged at least 70 years had better results with immediate angiography (P for interaction = .007), whereas patients with no prior CAD had better results with delayed angiography, and patients with prior CAD had better results with immediate angiography (P for interaction = .009).
“Patients older than 70 and with previous history of coronary artery disease might have more benefit with an immediate strategy compared with patients who are younger than 70 and without history of coronary artery disease,” he said.
‘Important step forward’
In a related editorial published in NEJM, Benjamin S. Abella, MD, MPhil, from the Center for Resuscitation Science and department of emergency medicine at the University of Pennsylvania Perelman School of Medicine, and David F. Gaieski, MD, from the department of emergency medicine at Jefferson University Hospital, Philadelphia, wrote that the trial “represents an important step forward in the care of patients after a cardiac arrest, and the results suggest that for the majority of comatose patients who have had a cardiac arrest without STEMI, coronary angiography need not be performed immediately.” – by Erik Swain
References:
Lemkes JS, et al. Late-Breaking Clinical Trials V. Presented at: American College of Cardiology Scientific Session; March 16-18, 2019; New Orleans.
Abella BS, et al. N Engl J Med. 2019;doi:10.1056/NEJMe1901651.
Lemkes JS, et al. N Engl J Med. 2019;doi:10.1056/NEJMoa1816897.
Disclosures: The study was sponsored by AstraZeneca, Biotronik and the Netherlands Heart Institute. Lemkes reports no relevant financial disclosures. Abella reports he has financial ties with Becton Dickinson, CPR Ready, JDP, Mallinckrodt, MD Ally, Medtronic Foundation and Stryker. Gaieski reports he has financial ties with Bard, BrainCool, Getinge and Stryker.