COACT Trial: Does Immediate Coronary Angiography After Cardiac Arrest Improve Survival?

Jorrit Lemkes, MD

Immediate coronary angiography after cardiac arrest did not improve survival at 1 year compared with a strategy of delayed procedure in patients successfully resuscitated from out of hospital cardiac arrest (OHCA) in the absence of ST segment elevation (STE), investigators in the Netherlands reported at the American Heart Association (AHA) 2019 Scientific Sessions in Philadelphia.

One-year clinical outcome data from the COronary Angiography after Cardiac arresT (COACT) trial demonstrate that 61.4% of patients in the immediate angiography group and 64.0% of patients in the delayed group were alive 1 year post-cardiac arrest (odds ratio [OR] 0.90; confidence interval [CI], 0.63-1.28).

Additionally, there were no significant differences in the rates of myocardial infarction, revascularization, hospitalization due to heart failure, or ICD shocks between the 2 treatment groups at 1 year, presenter Jorrit Lemkes, MD, Amsterdam University Medical Center, reported at AHA.

COACT is the first randomized study to analyze whether immediate versus delayed invasive strategy improves survival and major adverse cardiac events at 1 year in cardiac arrest patients without ST segment elevation. The investigator-initiated, open-label, multicenter trial enrolled 552 OHCA patients with return of spontaneous circulation (ROSC) and without STE. Patients were randomized 1:1 to receive either immediate angiography (n=264) or delayed angiography (n=258).

To be included in the trial, participants had to be >18 years, comatose (Glasgow coma score <8), with ROSC after OHCA. Patients in the immediate arm were 65.8±12.5 years old and 81.4% male sex, while patients in the delayed group were 65.0±12.2 years old and 76.7% male. The median time from arrest to ROSC was 15 minutes (IQR 8-20) across both groups.

Exclusion criteria included signs of STEMI on the ECG at the emergency department, hemodynamic instability unresponsive to medical therapy, and refractory ventricular arrhythmia, among others.

The primary end point was survival at 90 days, with short-term secondary end points including survival at 90 days with good cerebral performance or moderate disability, Thrombolysis in Myocardial Infarction major bleeding, recurrence of ventricular tachycardia, occurrence of acute kidney injury and need for renal-replacement therapy, time to target temperature, duration of inotropic/catecholamine support, duration of mechanical ventilation, myocardial injury, and markers of shock.

At 1 year, 2 out of 264 (0.8%) patients and 1 out of 258 (0.4%) patients suffered myocardial infarction in the immediate and delayed groups, respectively. The rate of any revascularization since index hospitalization was similar across both groups, as well, with 10/264 (3.8%) and 10/258 (3.9%) in the immediate and delayed groups, respectively.

The study, “One Year Outcomes of Coronary Angiography After Cardiac Arrest,” was presented Sunday, November 17, 2019, at AHA 2019.