Elsevier

American Heart Journal

Volume 180, October 2016, Pages 39-45
American Heart Journal

Trial Design
Coronary angiography after cardiac arrest: Rationale and design of the COACT trial

https://doi.org/10.1016/j.ahj.2016.06.025Get rights and content

Background

Ischemic heart disease is a major cause of out-of-hospital cardiac arrest. The role of immediate coronary angiography (CAG) and percutaneous coronary intervention (PCI) after restoration of spontaneous circulation following cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) remains debated.

Hypothesis

We hypothesize that immediate CAG and PCI, if indicated, will improve 90-day survival in post–cardiac arrest patients without signs of STEMI.

Design

In a prospective, multicenter, randomized controlled clinical trial, 552 post–cardiac arrest patients with restoration of spontaneous circulation and without signs of STEMI will be randomized in a 1:1 fashion to immediate CAG and PCI (within 2 hours) versus initial deferral with CAG and PCI after neurological recovery. The primary end point of the study is 90-day survival. The secondary end points will include 90-day survival with good cerebral performance or minor/moderate disability, myocardial injury, duration of inotropic support, occurrence of acute kidney injury, need for renal replacement therapy, time to targeted temperature control, neurological status at intensive care unit discharge, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, and reasons for discontinuation of treatment.

Summary

The COACT trial is a multicenter, randomized, controlled clinical study that will evaluate the effect of an immediate invasive coronary strategy in post–cardiac arrest patients without STEMI on 90-day survival.

Section snippets

Study design

COACT is a prospective, multicenter, randomized, controlled clinical study evaluating the effect of an immediate CAG in patients after OHCA on 90-day survival. A total of 14 centers in the Netherlands will enroll patients. These centers are all high-volume PCI centers with 24/7 STEMI service and extensive experience treating OHCA patients. Patients are eligible for the study if they have ventricular tachycardia or fibrillation during the arrest, have restoration of spontaneous circulation

Discussion

The effect of an immediate invasive strategy in patients after OHCA and without ECG signs of STEMI has been debated for some time. Several observational studies have reported on the effect of immediate CAG in OHCA patients on survival.6., 8., 9., 10., 11., 12., 13., 14., 15., 16., 17., 18. However, only a few have done so in the specific group of patients without signs of STEMI. Bro-Jeppesen et al15 found that immediate CAG was not associated with a reduction in mortality (HR adjusted = 0.69,

References (38)

  • D Stub et al.

    Usefulness of cooling and coronary catheterization to improve survival in out-of-hospital cardiac arrest

    Am J Cardiol

    (2011)
  • LM Batista et al.

    Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest

    Resuscitation

    (2010)
  • J Joffre et al.

    Stent thrombosis: an increased adverse event after angioplasty following resuscitated cardiac arrest

    Resuscitation

    (2014)
  • SO Rosillo et al.

    Is therapeutic hypothermia a risk factor for stent thrombosis?

    J Am Coll Cardiol

    (2014)
  • T Rab et al.

    Cardiac arrest: a treatment algorithm for emergent invasive cardiac procedures in the resuscitated comatose patient

    J Am Coll Cardiol

    (2015)
  • N Nielsen et al.

    Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest

    N Engl J Med

    (2013)
  • D Stub et al.

    Post cardiac arrest syndrome: a review of therapeutic strategies

    Circulation

    (2011)
  • CM Spaulding et al.

    Immediate coronary angiography in survivors of out-of-hospital cardiac arrest

    N Engl J Med

    (1997)
  • PG Steg et al.

    ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

    Eur Heart J

    (2012)
  • Cited by (23)

    • The effect of immediate coronary angiography after cardiac arrest without ST-segment elevation on left ventricular function. A sub-study of the COACT randomised trial

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      The COACT trial was an investigator-initiated, randomized, open-label, multicentre trial comparing immediate coronary angiography with delayed coronary angiography in patients successfully resuscitated from cardiac arrest without ST-segment elevation on the ECG. The trial design has been published previously.7 The protocol was designed by the principal authors and was approved by the steering committee (Supplementary Appendix) and all relevant ethics committees.

    • Data on sex differences in one-year outcomes of out-of-hospital cardiac arrest patients without ST-segment elevation

      2020, Data in Brief
      Citation Excerpt :

      Important exclusion criteria were signs of ST-segment elevation, shock or an obvious non-coronary cause [1]. Further in- and exclusion criteria were reported previously [3]. Eligible patients for the study were randomized in a 1:1 ratio to either immediate coronary angiography (i.e. within two hours after randomization) or delayed coronary angiography strategy until after neurological recovery.

    • Coronary angiographic findings after cardiac arrest in relation to ECG and comorbidity

      2020, Resuscitation
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      Previous retrospective studies present somewhat conflicting results3,6,13–15 thereby limiting the strength of current guidelines. Several ongoing randomized studies addressing this important question are currently including patients, and the results from these will certainly provide more knowledge about optimal strategy and timing concerning angiography.16,17 No difference in survival or neurologic outcome could be found in the newly published, first randomized trial investigating this important issue8 The finding in this trial of a lower rate of PCI (33% in patients randomized to immediate coronary angiography) compared to many of the previously published retrospective studies is interesting.

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    Trial registration number: NTR 4973 (www.trialregister.nl).

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