Coronary angiography after cardiac arrest without ST-Segment Elevation (The COACT trial)

Selected in The New England Journal of Medicine by E. Asher , S. Brugaletta

References

Authors

Lemkes JS, Janssens GN, van der Hoeven NW, Jewbali LSD, Dubois EA, Meuwissen M, Rijpstra TA, Bosker HA, Blans MJ, Bleeker GB, Baak R, Vlachojannis GJ, Eikemans BJW, van der Harst P, van der Horst ICC, Voskuil M, van der Heijden JJ, Beishuizen A, Stoel M, Camaro C, van der Hoeven H, Henriques JP, Vlaar APJ, Vink MA, van den Bogaard B, Heestermans TACM, de Ruijter W, Delnoij TSR, Crijns HJGM, Jessurun GAJ, Oemrawsingh PV, Gosselink MTM, Plomp K, Magro M, Elbers PWG, van de Ven PM, Oudemans-van Straaten HM, van Royen N

Reference

N Engl J Med. 2019 Mar 18 [Epub ahead of print]

Published

March 2019

Link

Read the abstract

Reviewers

Elad Asher

@AsherElad

Interventional cardiologist / Cardiologist

Shaarey Zedek Medical Center - Jerusalem, Israel

Salvatore Brugaletta

@sbrugaletta

Interventional cardiologist / Cardiologist

Barcelona, Spain

Our Comment

This joint review is part of the PCRonline GLOBAL Journal Club Initiative by selected members of the EAPCI/PCR Journal Club and PCR NextGen, and is based on the underlying idea of “Bringing peers together, exchanging ideas, towards a common standard of care”.

Why this study – the rationale/objective?

Acute coronary syndrome is a major cause of out-of-hospital cardiac arrest. Current European and American guidelines recommend immediate coronary angiography with percutaneous coronary intervention (PCI) in patients who present with ST-segment elevation myocardial infarction (STEMI) and cardiac arrest. Nevertheless, the role of immediate coronary angiography and PCI in the treatment of patients who have been successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction remains uncertain.

How was it executed – the methodology?

The COACT trial was a randomized, open-label, multicenter trial that compared a strategy of immediate coronary angiography vs. delayed angiography in patients who had been successfully resuscitated after cardiac arrest and who did not have ST-segment elevation on ECG.

Inclusion criteria: Out-of-hospital cardiac arrest with an initial shockable rhythm and unconsciousness after the return of spontaneous circulation (ROSC).
Exclusion criteria: Signs of STEMI on ECG in the emergency department, shock, or an obvious noncoronary cause of the arrest.
Patients were randomly assigned in a 1:1 ratio to either immediate angiography (as soon as possible and within 2 hours after randomization) or delayed angiography (after neurologic recovery, in general after discharge from the intensive care unit).
Targeted temperature management was initiated as soon as possible.
The primary end point of the trial was survival at 90 days.
Secondary end points included: survival at 90 days with good cerebral performance or mild or moderate disability, myocardial injury, acute kidney injury time to target temperature, duration of catecholamine or inotropic therapy, neurologic status at discharge from the intensive care unit, recurrence of ventricular tachycardia requiring defibrillation or electrical cardioversion, duration of mechanical ventilation, and major bleeding.

What is the main result?

During the period from January 2015 through July 2018, a total of 552 patients were enrolled (538 patients had data for assessment and comprised the study population) at 19 participating centers in the Netherlands.
Mean age was 65.3±12.6 years, and 79.0% of patients were men.
Coronary angiography was performed in 97.1% vs. 64.9% in the immediate and the delayed angiography groups, respectively. PCI was performed in 33.0% of patients in the immediate angiography group and in 24.2% in the delayed angiography group. Coronary artery bypass grafting was performed in 6.2% and 8.7%, respectively.
More than 90% of patients in each group were treated with targeted temperature management and mechanical ventilation.
Survival rate at 90 days was 64.5% vs. 67.2% in the immediate vs. delayed angiography groups, respectively. (OR, 0.89; 95% CI, 0.62 to 1.27; P = 0.51). No other major differences were found in the secondary endpoints.

Critical reading and the relevance for clinical practice

The COACT trial is the first randomized, multicenter trial involving patients who were successfully resuscitated after out-of-hospital cardiac arrest and no signs of STEMI or a non-coronary cause of the arrest. The trial clearly shows that immediate angiography was not better than a strategy of delayed angiography with respect to overall survival at 90 days. The findings are not in line with those previous observational studies, which showed a survival benefit with immediate coronary angiography. This difference could be related to the observational nature of the previous studies (i.e. selection bias that favoured treating patients who had a presumed better prognosis with a strategy of immediate angiography).
The high rate of neurological death may have reduced the benefit of early coronary intervention. Another explanation could be that patients assigned to the immediate angiography group reached their target temperature later than patients in the delayed angiography group.
Several study limitations should be highlighted: physicians were aware of the assigned group, and this information might have influenced subsequent treatment. Patients with shock, severe renal dysfunction, or persistent ST-segment elevation, and patients with non-shockable rhythm were excluded from the trial.

What is your approach regarding the timing of coronary angiography after cardiac arrest in patients without ST-Segment elevation in daily practice?

Read on the other major Late Breaking Trials presented at ACC 2019