Survival after cardiac arrest no different with emergency vs. delayed coronary angiogram
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Performing an emergency vs. delayed coronary angiogram after out-of-hospital cardiac arrest without ST segment elevation was not associated with greater 180-day survival rate or better neurologic outcomes, data from a randomized trial show.
“Several retrospective studies show that the probability of finding an acute coronary artery lesion during an early coronary angiogram is high (70%-80%) if ST segment elevation on the postresuscitation ECG is present,” Christian Spaulding, MD, PhD, professor of cardiology at Paris Descartes University and head of the interventional cardiology department at the European Hospital Georges Pompidou, and colleagues wrote in JAMA Cardiology. “Therefore, guidelines recommend performing an emergent coronary angiogram in survivors of sudden cardiac death with no obvious noncardiac cause of arrest and ST segment elevation. In patients with cardiac arrest without ST segment elevation on postresuscitation ECG, the benefit of an emergency coronary angiogram is still a matter of debate. In these patients, the rate of acute coronary artery lesion is much lower (15%-20%).”
For the EMERGE trial, Spaulding and colleagues assessed the 180-day survival rate with Cerebral Performance Category (CPC) score of 1 or 2 of 279 patients who experienced an out-of-hospital cardiac arrest without ST segment elevation on ECG randomly assigned emergency (50.5%) or delayed (49.5%) coronary angiogram in 22 French centers from January 2017 to November 2020. The mean age of patients was 65 years; 70% were men. Patients assigned to the emergency group were transferred directly to the catheterization lab; those assigned to the delayed group were admitted to the ICU with coronary angiogram planned 48 to 96 hours after admission.
“Survivors of out-of-hospital cardiac arrest are usually comatose after resuscitation, and they cannot provide an informed consent for participation in a trial,” the researchers wrote. “From January 2017 to 2019, if proxies were present on the site of cardiac arrest, they were asked to provide an informed consent before inclusion and randomization. Owing to difficulties in obtaining such a consent during prehospital care, an amendment was added to the protocol in September 2019 stating that a signed consent was no longer required for inclusion. The patient and/or family members (or next of kin) were informed as soon as possible, and their consent was sought for research to be continued.”
The primary outcome was the 180-day survival rate with a CPC score of 2 or less; secondary endpoints 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 ICU discharge and day 90; survival rate; and hospital length of stay.
The mean time delay between randomization and coronary angiogram was 0.6 hours in the emergency group and 55.1 hours in the delayed group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% in the emergency group and 30.7% in the delayed group, for an HR of 0.87 (95% CI, 0.65-1.15; P = .32). There was no difference in overall survival rate at 180 days for emergency (36.2%) vs. delayed coronary angiogram (33.3%; HR = 0.86; 95% CI, 0.64-1.15; P = .31). There were no between-group differences in secondary outcomes.
“The study patient enrollment goal was not achieved, and therefore, the study was underpowered to adequately assess the primary and secondary endpoints,” the researchers wrote. “However, our results are consistent with previously published studies and do not support emergency coronary angiogram in survivors of out-of-hospital cardiac arrest without ST elevation.”
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