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Immediate angiography after non-STEMI cardiac arrest confers no survival benefit

Key clinical point: Immediate coronary angiography after cardiac arrest does not confer a survival benefit over delayed angiography.

Major finding: At 90 days, survival rates were similar in patients who underwent immediate coronary angiography and those who underwent delayed angiography.

Study details: Randomized trial in 552 patients who survived cardiac arrest without STEMI.

Disclosures: The study was supported by the Netherlands Heart Institute, Biotronik and AstraZeneca. Two authors declared grants and support from the study supporters, both in the context of the study and outside it. One author declared grants from private industry outside the study. No other conflicts of interest were declared.

Citation:

Lemkes J et al. NEJM, 2019, March 18. DOI: 10.1056/NEJMoa1816897.

Commentary:

The results of the COACT trial are consistent with other studies in patients with acute coronary syndromes but without evidence of STEMI or cardiac arrest, showing that immediate coronary angiography is not associated with improved outcomes.

However, less than 20% of the COACT cohort had unstable coronary lesions and less than 40% underwent coronary interventions, so relatively few patients would have been affected by the timing of coronary angiography or the procedure itself. In this trial, more than 60% of deaths were due to neurologic injury rather than cardiac complications.


Enriching the study population with patients with probable coronary disease might have led to a different result. A substudy analysis of patients over age 70 with a history of coronary disease showed they were more likely to benefit from immediate coronary angiography than were younger patients without a history of coronary disease.


Prioritizing interventions also had an impact on targeted temperature managemen, which also may have played into the results. The median time to achieve target temperature was 5.4 hours in the immediate angiography group and 4.7 hours in the delayed angiography group.
Additional insights may come from two ongoing clinical trials, ACCESS and DISCO (Direct or Subacute Coronary Angiography in Out-of-hospital Cardiac Arrest), may shed additional light on how interventions after out-of-hospital cardiac arrest affect patient outcomes.


Dr. Benjamin S. Abella is from the Center for Resuscitation Science and Department of Emergency Medicine at the University of Pennsylvania Perelman School of Medicine and Dr. David F. Gaieski is from the Department of Emergency Medicine at Jefferson Medical College. These comments are adapted from an accompanying editorial (NEJM 2019, March 18. DOI: 10.1056/NEJMe1901651). Both authors declared grants, personal support and other support from private industry outside the submitted work.