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Randomized Controlled Trial
. 2022 Jul 1;7(7):700-707.
doi: 10.1001/jamacardio.2022.1416.

Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial

Caroline Hauw-Berlemont  1 , Lionel Lamhaut  2   3   4 , Jean-Luc Diehl  1   5 , Christophe Andreotti  6 , Olivier Varenne  7 , Pierre Leroux  8 , Jean-Baptiste Lascarrou  9 , Patrice Guerin  10 , Thomas Loeb  11 , Eric Roupie  12 , Cédric Daubin  13 , Farzin Beygui  14 , Florence Boissier  15 , Nicolas Marjanovic  16 , Luc Christiaens  17 , Aurélie Vilfaillot  18 , Sophie Glippa  18 , Juliette Djadi Prat  18 , Gilles Chatellier  18 , Alain Cariou  19 , Christian Spaulding  20 ; EMERGE Investigators
Collaborators, Affiliations
Randomized Controlled Trial

Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial

Caroline Hauw-Berlemont et al. JAMA Cardiol. .

Abstract

Importance: Although an emergency coronary angiogram (CAG) is recommended for patients who experience an out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the postresuscitation electrocardiogram (ECG), this strategy is still debated in patients without ST-segment elevation.

Objective: To assess the 180-day survival rate with Cerebral Performance Category (CPC) 1 or 2 of patients who experience an OHCA without ST-segment elevation on ECG and undergo emergency CAG vs delayed CAG.

Design, setting, and participants: The Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) trial randomly assigned survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG in 22 French centers. The trial took place from January 19, 2017, to November 23, 2020. Data were analyzed from November 24, 2020, to July 30, 2021.

Main outcomes and measures: The primary outcome was the 180-day survival rate with CPC of 2 or less. The secondary end points were occurrence of shock, ventricular tachycardia, and/or fibrillation within 48 hours, change in left ventricular ejection fraction between baseline and 180 days, CPC scale at intensive care unit discharge and day 90, survival rate, and hospital length of stay.

Results: A total of 279 patients (mean [SD] age, 64.7 [14.6] years; 195 men [69.9%]) were enrolled, with 141 (50.5%) in the emergency CAG group and 138 (49.5%) in the delayed CAG group. The study was underpowered. The mean (SD) time delay between randomization and CAG was 0.6 (3.7) hours in the emergency CAG group and 55.1 (37.2) hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (hazard ratio [HR], 0.87; 95% CI, 0.65-1.15; P = .32). There was no difference in the overall survival rate at 180 days (emergency CAG, 36.2% [51 of 141] vs delayed CAG, 33.3% [46 of 138]; HR, 0.86; 95% CI, 0.64-1.15; P = .31) and in secondary outcomes between the 2 groups.

Conclusions and relevance: In this randomized clinical trial, for patients who experience an OHCA without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequelae.

Trial registration: ClinicalTrials.gov Identifier: NCT02876458.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Hauw-Berlemont reported receiving grants from the French Ministry of Health during the conduct of the study. Dr Lamhaut reported receiving grants from the French Ministry of Health during the conduct of the study. Dr Varenne reported receiving grants from Abbott Medical and Boston Scientific during the conduct of the study; personal fees from Servier; and nonfinancial support from Astra Zeneca and Biosensors outside the submitted work. Dr Lascarrou reported receiving personal fees from Bard Pharmaceuticals and Zoll during the conduct of the study. Dr Guerin reported receiving personal fees from Abbott Medical and grants from Edwards during the conduct of the study. Ms Glippa and Dr Prat reported receiving grants from the French Ministry of Health during the conduct of the study. Dr Cariou reported receiving lecture fees from Bard during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Flow Diagram
CAG indicates coronary angiogram; ITT, intention to treat.
Figure 2.
Figure 2.. Patient Survival With a Cerebral Performance Category (CPC) Score of 1 or 2
CAG indicates coronary angiogram.
Figure 3.
Figure 3.. Summary of Randomized Clinical Trials Comparing Emergency vs Delayed Coronary Angiogram (CAG) in Patients With Cardiac Arrest Without ST-Segment Elevation
COACT indicates Coronary Angiography After Cardiac Arrest; EMERGE, Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest; PEARL, Randomized Pilot Clinical Trial of Early Coronary Angiography vs No Early Coronary Angiography for Postcardiac Arrest Patients Without ST-Segment Elevation; TOMAHAWK, Immediate Unselected Coronary Angiography vs Delayed Triage in Survivors of Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation.
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