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Until recently, the optimal timing of performing coronary angiography in patients successfully resuscitated from out-of-hospital cardiac arrest (OHCA) with initial shockable rhythm and absence of ST-segment elevation was unknown.
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In the past, a large Dutch cohort study reported no difference in 30-day all-cause mortality between early and delayed coronary angiography.
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With 19 participating Dutch hospitals, the Coronary Angiography after Cardiac Arrest without ST-segment elevation (COACT) was the first randomised trial that provided comparative information between coronary angiography treatment strategies in these patients.
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The COACT trial found that a strategy of immediate angiography was not better than delayed coronary angiography with respect to 90-day survival.
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Except for a longer time to targeted temperature in the immediate coronary angiography group, no significant differences were found in the remaining secondary endpoints (i.e. myocardial injury, inotropic and catecholamine support or recurrent ventricular arrhythmias).
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Further outcome data concerning long-term mortality as well as additional determinants from the COACT trial are to be expected.
Introduction
The clinical conundrum in post-arrest care
Observational studies: delayed versus immediate coronary angiography
Author, year of publication | No. of patients | Comparative treatment | Initial rhythm | ECG inclusion criteria | Primary endpoint | Outcome |
---|---|---|---|---|---|---|
Bro-Jeppesen, 2012 [31] | 244 | Early (<12 h) vs. late/no angiography | All initial rhythms | All ECGs | Survival at 30 days and 1 year | Early angiography was not associated with reduced mortality |
Hollenbeck, 2014 [26] | 269 | Early (while comatose) vs. late/no angiography | VF/pVT | Absence of STEMI | Survival to hospital discharge | Early angiography is associated with decreased mortality |
Reynolds, 2014 [36] | 191 | Early (directly) vs. late/no angiography | All initial rhythms | All ECGs | Good outcome (discharge home/rehabilitation) | Prompt revascularisation is achievable in OHCA at almost every measured stratum of illness severity |
Vyas, 2015 [33] | 4029 | Early (<24 h) vs. late/no angiography | VF/pVT/unknown | All ECGs | Survival to hospital discharge | Early angiography is associated with higher odds of survival |
Kleissner, 2015 [30] | 99 | Early (<2 h) vs. late/no angiography | All initial rhythms | Absence of STEMI and LBBB | In-hospital and 6‑month mortality and neurological performance | Early angiography was not better than conservative approach |
Dankiewicz, 2015 [25] | 544 | Early (<6 h) vs. late/no angiography | All initial rhythms | Absence of STEMI | Mortality at the end of the trial | Early angiography is not associated with improved survival |
Kern, 2015 [32] | 746 | Early (<2 h) vs. late/no angiography | All initial rhythms | All ECGs | Survival to discharge | Early angiography is associated with improved outcome |
Garcia, 2016 [34] | 203 | Early (<6 h) vs. late/no angiography | VF/pVT | All ECGs | Survival to hospital discharge with favourable neurologic outcome | Early angiography is associated with good survival with favourable neurological outcomes |
Staudacher, 2018 [27] | 612 | Early (<3 h) vs. no/late angiography | All initial rhythms | All ECGs | All-cause mortality at 30 days | Early angiography was not associated with reduced mortality |
Elfwén, 2018 [13] | 799 | Early (<24 h) vs. late/no angiography | VF/pVT | Absence of STEMI | Survival at 30 days, 1 year, 3 years | Early angiography may be associated with improved survival |
Kim, 2019 [35] | 227 | Immediate (<2 h) vs. early (2–24 h) angiography | All initial rhythms | Absence of STEMI and LBBB | Good neurological outcome at 1 month | No clear neurological benefit of immediate angiography |