Immediate Angiography Not Preferred Over Delayed or Selective Strategies

Steffen Desch, MD

Investigators from Germany found that among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, an immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause.

The findings of the study were presented at the European Society of Cardiology (ESC) 2021 Congress this weekend.

The team, led by Steffen Desch, MD, Heart Center Leipzig at the University of Leipzig, Departments of Internal Medicine–Cardiology, noted that the prognosis of patient who experience out-of-hospital cardiac arrest is often poor, with mortality rates of up to 65%.

Despite myocardial infraction being a frequent cause of out-of-hospital cardiac arrest, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation were unclear.

A recent randomized trial involving patients with cardiac arrest without ST-segment elevation that compared immediate angiography with delayed angiography showed no significant between group difference.

However, the investigators felt the evidence was limited regarding the general indication and timing of coronary angiography in patients with out-of-hospital cardiac arrest, including those with non-shockable rhythm.

As such, the recent study evaluated the possible superiority of routine immediate coronary angiography.

The Study

In the multicenter trial, Desch and colleagues evaluated 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin.

If eligibility criteria were met, patients in the study were randomly assigned to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment and delayed or selective angiography (delayed-angiography group).

Patients in the former group were transferred to the catheterization laboratory after hospital admission, while the latter were transferred to the intensive care unit (ICU) for further evaluation.

Coronary angiography was performed in 95.5% of patients in the immediate-angiography group and in 62.2% of those in the delayed-angiography group.

A total of 13 patients (4.6%) in the immediate-angiography group did not undergo immediate cardiac catheterization, with 6 of those patients dying before immediate coronary angiography. The remaining 7 patients did not receive the allocated intervention.

In the delayed-angiography group, 22 patients (8.1%) underwent coronary angiography within the first 24 hours after hospital admission without fulfilling protocol-specified clinical criteria for early catheterization.

The primary end point was death from any cause at 30 days, and some of the key secondary efficacy end points were myocardial infarction at 30 days, neurologic deficit, and a composite of death from any cause or severe neurologic deficit.

The Results

At 30 days, the primary end point of death from any cause had occurred in 143 of 265 patients (54.0%) in the immediate angiography group and in 122 of 265 patients (46.0%) in the delayed-angiography group.

Similarly, The prevalence of coronary artery disease among patients who underwent cardiac catheterization was 60.7% in the immediate-angiography group and 72.1% in the delayed-angiography group.

The overall frequency of coronary revascularization was 39.6%.

Though the composite secondary end point of death from any cause or severe neurologic deficit occurred more frequently in the immediate-angiography group than in the delayed-angiography group.

The investigators did not consider this a “true finding”, however, noting that immediate coronary catheterization could lead to delays in diagnosing other triggers.

Overall, the current supported those found in the Coronary Angiography after Cardiac Arrest (COACT) trial, which showed no significant differences in the 2 patient groups of the current study.

“Thus, among patients with resuscitated out-of-hospital cardiac arrest with a possible cardiac cause without ST-segment elevation, an immediate coronary angiography strategy was not found to be beneficial over a delayed or selective strategy with respect to the 30-day risk of death from any cause.”

Despite this, Desch and colleagues noted several ongoing trials were addressing similar research questions, and that early revascularization may have benefits outside the outcome measures that were studied in the current analysis.