Timing or patient choice in coronary angiography?
PHILADELPHIA – Immediate coronary angiography following restoration of spontaneous circulation after out-of-hospital cardiac arrest without ST-elevation MI (STEMI) offered no survival benefit at 1 year, compared with a strategy of delaying angiography until after neurologic recovery, in the landmark COACT trial, Jorrit Lemkes, MD, reported at the American Heart Association scientific sessions.
Bruce Jancin/MDedge News
Dr. Jorrit Lemkes
Nor was immediate coronary angiography advantageous in terms of any of the numerous secondary long-term endpoints, including rates of MI, revascularization, hospitalization for heart failure, implantable cardioverter defibrillator (ICD) shocks, or quality of life measures (see graphic), according to Dr. Lemkes, an interventional cardiologist at Amsterdam University Medical Center.
COACT, a 552-patient randomized trial conducted at 19 Dutch centers, was the first-ever randomized trial to evaluate the role of immediate coronary angiography in patients resuscitated from out-of-hospital cardiac arrest with no signs of ST elevation on ECG. The study hypothesis was that this practice would result in improved survival and other outcomes. But such was not the case in the previously reported 90-day analysis (N Engl J Med. 2019 Apr 11;380[15]:1397-407). Nonetheless, the new 1-year results were eagerly awaited because observational data had suggested that immediate angiography after cardiac arrest without STEMI might provide a survival advantage that manifests late.
It now appears the observational studies were misleading. The 1-year survival rate was 61.4% in the immediate angioplasty group and similar at 64% with delayed angioplasty.
By way of background, Dr. Lemkes noted that both European and American guidelines give a class 1 recommendation to immediate coronary angiography with percutaneous coronary intervention (PCI) in patients who present with STEMI and cardiac arrest. It’s an endorsement grounded in compelling clinical trials evidence demonstrating that this practice reduces mortality and recurrent ischemia, salvages myocardium, and restores left ventricular function. In contrast, current guidelines offer only a tepid recommendation for immediate PCI in patients with cardiac arrest without STEMI because the only supporting evidence has been observational, with its inherent susceptibility to bias.
Discussant Joaquin E. Cigarroa, MD, said that the 1-year outcomes shouldn’t be surprising, since the 90-day results failed to show any between-group differences in myocardial injury or ischemia.
“At present, the results of COACT with regards to primary and secondary outcomes should guide practitioners that angiography remains essential, but that early angiography does not improve outcomes, compared to delayed angiography,” declared Dr. Cigarroa, chief of cardiology and professor of medicine at Oregon Health & Science University, Portland.
His choice of the words “at present” was key, as COACT won’t be the last word on the subject. Dr. Cigarroa believes that it’s critically important to understand the relatively narrow profile of the patients included in the study, because the results may or may not prove to be generalizable to the broader population of out-of-hospital cardiac arrest patients encountered in clinical practice. Nearly 80% of COACT participants had a witnessed arrest, the median time to basic life support was just 2 minutes, and the median time to return of spontaneous circulation was 15 minutes.
He urged his colleagues to stay tuned for reports from ongoing randomized trials examining the potential role of immediate angiography in broader populations of patients with out-of-hospital cardiac arrest without STEMI, including the Swedish DISCO (Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest) trial and the smaller University of Minnesota–sponsored ACCESS trial.
Dr. Lemkes reported having no financial conflicts regarding the COACT trial, funded by the Netherlands Heart Institute and unrestricted research grants from Biotronik and AstraZeneca.