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Original Investigation
September 2, 2020

Coronary Angiography After Cardiac Arrest Without ST Segment Elevation: One-Year Outcomes of the COACT Randomized Clinical Trial

Author Affiliations
  • 1Department of Cardiology, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
  • 2Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands
  • 3Department of Cardiology, Amphia Hospital, Breda, the Netherlands
  • 4Department of Intensive Care Medicine, Amphia Hospital, Breda, the Netherlands
  • 5Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
  • 6Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, the Netherlands
  • 7Department of Cardiology, HAGA Hospital, Den Haag, the Netherlands
  • 8Department of Intensive care medicine, HAGA Hospital, Den Haag, the Netherlands
  • 9Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
  • 10Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, the Netherlands
  • 11Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
  • 12Department of Intensive Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
  • 13Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
  • 14Department of Intensive Care Medicine, Maastricht University Medical Center, University Maastricht, Maastricht, the Netherlands
  • 15Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
  • 16Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
  • 17Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands
  • 18Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
  • 19Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
  • 20Department of Cardiology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
  • 21Department of Intensive Care Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
  • 22Department of Cardiology, OLVG, Amsterdam, the Netherlands
  • 23Department of Intensive Care Medicine, OLVG, Amsterdam, the Netherlands
  • 24Department of Cardiology, Noord West Ziekenhuisgroep, Alkmaar, the Netherlands
  • 25Department of Intensive Care Medicine, Noord West Ziekenhuisgroep, Alkmaar, the Netherlands
  • 26Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
  • 27Department of Cardiology, Scheper Hospital, Emmen, the Netherlands
  • 28Department of Cardiology, Haaglanden Medical Center, Den Haag, the Netherlands
  • 29Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
  • 30Department of Cardiology, Ter Gooi Hospital, Blaricum, the Netherlands
  • 31Department of Cardiology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
  • 32Department of Intensive Care Medicine, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
  • 33Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
JAMA Cardiol. 2020;5(12):1358-1365. doi:10.1001/jamacardio.2020.3670
Key Points

Question  Is coronary angiography performed immediately after cardiac arrest associated with improved clinical outcomes at 1 year in patients without signs of ST-segment elevation myocardial infarction?

Findings  In this follow-up of a randomized clinical trial that included 552 patients, there was no significant difference in clinical outcomes at 1 year between patients in the immediate angiography group compared with patients whose angiography was delayed until after neurologic recovery. Survival at 1 year was 61.4% in the immediate group vs 64.0% in the delayed group.

Meaning  The findings of this trial suggest that immediate coronary angiography is not associated with improved clinical outcomes at 1 year in patients after cardiac arrest without signs of ST segment elevation myocardial infarction.

Abstract

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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