One-Year Outcomes of Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST Elevation: An Individual Patient Data Meta-Analysis

Abstract

Importance: Several randomized clinical trials (RCTs) assessed the effect of immediate vs delayed coronary angiography in patients with out-of-hospital cardiac arrest (OHCA) without ST-segment elevations and found no difference in short-term survival. However, the association of these strategies with long-term outcomes and the identification of patient subgroups that might benefit from tailored approaches remain unclear.

Objective: To compare immediate vs delayed or selective coronary angiography treatment strategies for patients with OHCA without ST elevation and the effect on 1-year survival, and identify subgroups that may differ in treatment effect based on patient or clinical features.

Data sources: Ovid MEDLINE, Embase, and Clarivate/Web of Science Core Collection were searched for relevant literature from inception to September 8, 2022.

Study selection: RCTs investigating immediate vs delayed or selective coronary angiography after OHCA without ST-segment elevations and a minimum follow-up period of 1 year. Data were combined using the 1-stage individual participant data meta-analysis (IPDMA) approach.

Data extraction and synthesis: Individual patient data were obtained from RCTs that met the eligibility criteria: COACT (Coronary Angiography After Cardiac Arrest) and TOMAHAWK (Immediate Unselected Coronary Angiography vs Delayed Triage in Survivors of Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation).

Main outcomes and measures: The primary end point was 1-year survival. Secondary outcomes included the identification of variations in treatment effect using subgroup analysis (based on age, sex, arrest rhythm, witnessed arrest, time to basic life support, time to return of spontaneous circulation, and history of coronary artery disease, diabetes, and hypertension) and clinical outcomes (eg, myocardial infarction and heart failure) at 1 year.

Results: For the IPDMA, data were derived from 2 RCTs comprising a total of 1031 patients. In the immediate angiography group, 259 of 522 (49.6%) survived until 1 year vs 272 of 509 (53.4%) in the delayed or selective angiography group (stratified by randomized trial; hazard ratio, 1.15 [95% CI, 0.96-1.37). No treatment-by-subgroup interactions were identified that suggested heterogeneity between the 2 groups (P values for interaction ranged from P = .26 to P = .91 across subgroups).

Conclusions and relevance: In this IPDMA of 2 RCTs, there was no benefit of immediate coronary angiography compared with a delayed or selective strategy during 1-year follow-up in successfully resuscitated patients with OHCA without ST-segment elevations. No subgroup of patients was identified that showed a differential treatment effect.

Trial registration: PROSPERO Identifier: CRD42022346559; COACT Netherlands Trial Register Identifier: NTR4973; TOMAHAWK ClinicalTrials.gov Identifier: NCT02750462.