Coronary Angiography After Cardiac Arrest - COACT

Contribution To Literature:

The COACT trial showed that immediate angiography with an intent to revascularize is not superior to delayed angiography among patients presenting with out-of-hospital cardiac arrest secondary to a shockable rhythm and with no ECG evidence of ST-segment elevations post-ROSC.

Description:

The goal of the trial was to compare the safety and efficacy of emergent coronary angiography with percutaneous coronary intervention (PCI) if indicated compared with delayed angiography among patients presenting with out-of-hospital cardiac arrest who did not have ST-segment elevation on electrocardiogram (ECG) post–return of spontaneous circulation (ROSC).


Study Design

Eligible patients were randomized in a 1:1 fashion to either emergent angiography (n = 273) or delayed angiography (n = 265). In the delayed arm, coronary angiography was performed after neurological recovery, in general after the patient was moved out of the intensive care unit. Median times to angiography post-arrest were 2.3 hours for emergent vs. 121.9 hours for delayed angiography. The intent of angiography was to revascularize any possible culprit lesions, either with PCI or coronary artery bypass grafting. Targeted temperate management was initiated as soon as possible.

  • Total number of enrollees: 538
  • Duration of follow-up: 90 days
  • Mean patient age: 65 years
  • Percentage female: 20%

Inclusion criteria:

  • Initial shockable rhythm
  • Unconscious after ROSC
  • No ST-segment elevation on ECG post-ROSC

Exclusion criteria:

  • ST-segment elevation myocardial infarction (STEMI)
  • Shock
  • Obvious noncoronary cause of the arrest

Other salient features/characteristics:

  • Witnessed arrest: 78%
  • Median time from arrest to ROSC: 15 minutes
  • Median Glasgow Coma Score (GCS) on admission: 3
  • Mean pH: 7.2
  • Severity of coronary artery disease (CAD) on angiography: no significant CAD: 35%, one-vessel CAD: 28%, two-vessel disease: 20%, three-vessel disease: 17%, acute thrombotic lesion: 5%
  • PCI: 33.0% vs. 24.2% for emergent vs. delayed angiography, respectively

Principal Findings:

The primary outcome, survival to 90 days for immediate vs. delayed angiography, was 64.5% vs. 67.2% (p = 0.51).

Secondary outcomes for immediate vs. delayed angiography:

  • Survival with good cerebral performance or mild/moderate disability: 62.9% vs. 64.4% (p > 0.05)
  • Survival to hospital discharge: 65.2% vs. 68.7% (p > 0.05)
  • TIMI major bleeding: 2.6% vs. 4.9%
  • Need for renal replacement therapy: 2.9% vs. 4.2%

Interpretation:

The results of this trial indicate that immediate angiography with an intent to revascularize is not superior to delayed angiography among patients presenting with out-of-hospital cardiac arrest secondary to a shockable rhythm and with no ECG evidence of ST-segment elevations post-ROSC. Only 5% of patients had evidence of a true thrombotic lesion on angiography. These are very important findings and will likely influence guidelines on this topic.

References:

Lemkes JS, Janssens GN, van der Hoeven NW, et al. Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation. N Engl J Med 2019;Mar 18:[Epub ahead of print].

Editorial: Abella BS, Gaieski DF. Coronary Angiography After Cardiac Arrest — The Right Timing or the Right Patients? N Engl J Med 2019;Mar 18:[Epub ahead of print].

Presented by Dr. Jorrit Lemkes at the American College of Cardiology Annual Scientific Session (ACC 2019), New Orleans, LA, March 18, 2019.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: ACC19, ACC Annual Scientific Session, Arrhythmias, Cardiac, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Electrocardiography, Heart Arrest, Out-of-Hospital Cardiac Arrest, Percutaneous Coronary Intervention, Renal Replacement Therapy, Resuscitation, Thrombosis


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