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Randomized Controlled Trial
. 2020 Dec 1;5(12):1358-1365.
doi: 10.1001/jamacardio.2020.3670.

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

Jorrit S Lemkes  1 , Gladys N Janssens  1 , Nina W van der Hoeven  1 , Lucia S D Jewbali  2 , Eric A Dubois  2 , Martijn M Meuwissen  3 , Topm A Rijpstra  4 , Hans A Bosker  5 , Michiel J Blans  6 , Gabe B Bleeker  7 , Remon R Baak  8 , George J Vlachojannis  9 , Bob J W Eikemans  10 , Pim van der Harst  11   12 , Iwan C C van der Horst  13   14 , Michiel Voskuil  13 , Joris J van der Heijden  15 , Albertus Beishuizen  16 , Martin Stoel  17 , Cyril Camaro  18 , Hans van der Hoeven  19 , Jose P Henriques  20 , Alexander P J Vlaar  21 , Maarten A Vink  22 , Bas van den Bogaard  23 , Ton A C M Heestermans  24 , Wouter de Ruijter  25 , Thijs S R Delnoij  14 , Harry J G M Crijns  26 , Gillian A J Jessurun  27 , Pranobe V Oemrawsingh  28 , Marcel T M Gosselink  29 , Koos Plomp  30 , Michael Magro  31 , Paul W G Elbers  32 , Eva M Spoormans  1 , Peter M van de Ven  33 , Heleen M Oudemans-van Straaten  32 , Niels van Royen  1   18
Affiliations
Randomized Controlled Trial

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

Jorrit S Lemkes et al. JAMA Cardiol. .

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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Conflict of interest statement

Conflict of Interest Disclosures: Dr Lemkes reported receiving grants from The Netherlands Heart Institute and Biotronik during the conduct of the study. Dr Vlachojannis reported receiving grants from Daiichi Sankyo and MicroPort, and personal fees from AstraZeneca, Abbott, and Terumo outside the submitted work. Dr Vlaar reported receiving grants from Edwards Life Science outside the submitted work. Dr van Royen reported receiving grants from AstraZeneca and Biotronik during the conduct of the study; grants from Abbott, Biotronik, and Philips outside the submitted work; grants and personal fees from AstraZeneca; and personal fees from MicroPort and Amgen outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flowchart
Inclusion, treatment allocation, informed consent procedure, and lost to follow-up of COACT participants from the start of the trial up to 1 year. COACT indicates Coronary Angiography After Cardiac Arrest; OHCA, out of hospital cardiac arrest; and ROSC, return of spontaneous circulation. aThese patients received urgent intervention owing to conditions such as cardiogenic shock, recurrent life-threatening arrhythmias, or recurrent cardiac ischemia while waiting for coronary angiography.
Figure 2.
Figure 2.. Estimates of Survival Among Patients Who Underwent Immediate or Delayed Coronary Angiography After Cardiac Arrest
A, Estimates of survival: hazard ratio (HR) for death, 1.09 (95% CI, 0.83-1.45). B, Landmark analysis: HR for death from 0 to 90 days, 1.11 (95% CI, 0.83-1.49), and HR for death from 90 days to 1 year, 0.85 (95% CI, 0.26-2.78).
See this image and copyright information in PMC

References

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