For cardiac arrest survivors without ST elevation, immediate angiography and PCI no better than delayed (COACT)

Reference

Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary angiography after cardiac arrest without ST-segment elevation. N Engl J Med 2019;380(15):1397-1407.

Synopsis

In patients who initially survive an OHCA and have ST elevation, immediate coronary angiography, with PCI if indicated, is recommended. However, it is unclear whether this approach is necessary in patients with non-ST elevation myocardial infarction. For this study, the authors identified patients who experienced OHCA, had an initial shockable rhythm, and were unconscious after the return of spontaneous circulation. Patients with ST elevation, shock, or a clear noncardiac cause for arrest were excluded. A total of 552 patients were initially randomized to receive either coronary angioplasty immediately, with PCI if indicated, or angiography delayed until neurologic recovery (generally characterized by discharge from the intensive care unit [ICU]). If patients in the delayed group became unstable or had a clear indication for it, they could undergo angioplasty. Retroactive withdrawal of consent occurred in 11 patients in the delayed group and 3 in the immediate group. Groups were fairly well balanced at the start of the study, with mean age of 65 years, 79% men, and 27% with a previous myocardial infarction. The study was powered to detect a 40% relative difference in survival between groups, and analysis was by intention to treat. There was no significant difference between groups in 90-day survival (64.5% immediate vs 67.2% delayed), neurologic function at ICU discharge, or any other outcomes. Overall, 13 patients in the immediate angiography group crossed over to delayed angiography, and 3 assigned to delayed angiography had immediate angiography instead. Of the 265 patients in the delayed angiography group, 38 required urgent angiography at some point before their scheduled (delayed) procedure.