Ischemic heart disease is the most frequent cause of out-of-hospital cardiac arrest, a leading cause of death in Europe and the United States. The COACT (Coronary Angiography after Cardiac Arrest) trial investigated whether immediate angiography after resuscitation from cardiac arrest would have better outcome as compared to delayed angiography in terms of overall survival at 90 days. All patients were without ST-segment elevation on ECG.
Patients from 19 centers in the Netherlands were randomized 1:1 to immediate angiography (n = 273) or delayed angiography (n = 265). Immediate angiography was performed 0.8 hours after randomization, while delayed angiography was performed 119.9 hours after randomization and once patients’ neurological recovery was achieved. The primary endpoint was survival at 90 days.
So what did the authors find?
Immediate angiography was not better than delayed angiography in non-STEMI patients
No significant differences were seen in overall survival at 90 days between immediate vs delayed angiography. In particular, 64.5% (n = 176) of the patients in the immediate angiography group and 67.2% (n = 178) of the patients in the delayed angiography group survived at 90 days (OR = 0.89, 95% CI: 0.62 to 1.27, p = 0.51).
Once again we have a situation where we have a wealth of data pointing in one direction and then we try to validate this in a randomized trial and the data are pointing in another direction”– Professor Niels van Royen, COACT Trial Principal investigator, Radboud University Medical Center, Netherlands
This study showed that an immediate angiography strategy was no better than a delayed angiography in terms of survival at 90 days in patients successfully resuscitated after out-of-hospital cardiac arrest and no signs of ST-segment elevation on ECG.
A very specific take-home message for patients with out-of-hospital cardiac arrest without signs of ST-elevation, there is no need for an immediate invasive strategy. So as a physician, you have some time to think about the specific situation, the specific patient and then to decide either for an immediate invasive strategy, or wait, bring the patient to the ICU and eventually do the angiography at a later point in time.“– Professor Niels van Royen
Why was there no benefit in immediate angiography in this cohort?
The authors report that the lack of benefit for early coronary intervention may have been due to a lack of neurologic recovery prior to treatment. Majority of nonsurvivors in the early invasive group died of neurologic complications after cardiac arrest. Previous studies have also shown that death from neurologic injury was three times greater than death from cardiac causes. Thus, neurologic recovery may be the culprit of most death or adverse outcomes after cardiac arrest and should be focused on in future studies.
Differences in antiplatelet therapy in the different groups did not result in significant difference in Thrombolysis in Myocardial Infarction (TIMI) major bleeding. Patients that underwent delayed angiography received salicylates or P2Y12 inhibitor (or both), while patients in the immediate angiography group were more likely to receive glycoprotein IIb/IIIa inhibitor. Glycoprotein IIb/IIIa inhibitor is more often used in the event of urgent PCI of thrombotic lesions.
The authors conclude from this randomized multicenter trial, patients successfully resuscitated after out-of-hospital cardiac arrest and had a shockable rhythm, with no signs of STEMI or a noncoronary cause of cardiac arrest, an immediate angiography strategy was not better than delayed angiography in relation to overall survival at 90 days.
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Author: Lorena Casadonte
Original article: Lemkes et al. N Engl J Med. 2019 Jul 11;381(2):189-190.