COACT: No survival benefit with immediate vs delayed angiography for cardiac arrest without STEMI

Immediate coronary angiography does not improve survival at 1 year in patients who were successfully resuscitated from an OHCA* without ST-segment elevation myocardial infarction (STEMI) compared with delayed coronary angiography, according to the COACT** trial presented at AHA 2019.

“Guidelines recommend immediate coronary angiography with PCI*** in patients who present with STEMI and cardiac arrest … [While] in patients with cardiac arrest without ST-segment elevation, guidelines also recommend emergency angiography … [a] weak recommendation, [with a] very-low-quality evidence,” said Dr Jorrit Lemkes from Amsterdam University Medical Center in Amsterdam, Netherlands.

The researchers conducted an open-label, multicentre trial involving OHCA patients (mean age 65 years, 80 percent male) who were randomized in a 1:1 ratio to undergo either immediate (performed within 2 hours after randomization; n=264) or delayed (performed after neurologic recovery; n=258) coronary angiography. [AHA 2019, abstract LBS.04]

At 1 year, the survival rates were comparable between the immediate and delayed angiography groups (61.4 percent vs 64.0 percent; odds ratio [OR], 0.90, 95 percent confidence interval [CI], 0.63–1.28).

Patients who underwent immediate or delayed angiography also showed no significant difference with regards to other clinical outcomes, such as myocardial infarction (0.8 percent vs 0.4 percent; OR, 1.96), revascularization (3.8 percent vs 3.9 percent; OR, 0.98), PCI (3.0 percent vs 3.1 percent; OR, 0.98), CABG (0.8 percent vs 0.8 percent; OR, 0.98), hospitalization due to heart failure (0.8 percent vs 0.4 percent; OR, 1.96), and ICD⁺ shock (20.4 percent vs 16.2 percent; OR, 1.32) since index hospitalization.

Invited discussant Dr Joaquin Cigarroa from Oregon Health & Science University in Portland, Oregon, US, who is unaffiliated with the study, commented that “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”.

With regard to quality of life, as measured by RAND-36 questionnaire, both the immediate and delayed angiography groups also showed similar physical (49.2 percent vs 50.4 percent) and mental summary scores (51.3 percent vs 50.0 percent).

The findings were consistent with their previous study which revealed that immediate angiography did not improve overall survival at 90 days than the delayed angiography. [N Engl J Med 2019;380:1397-1407]

“[This trial showed that] in patients with ROSC⁺⁺ after OHCA without signs of STEMI, immediate coronary angiography was not found to improve survival at 1 year compared to delayed coronary angiography,” Lemkes concluded.

*OHCA: Out-of-hospital cardiac arrest

**COACT: Coronary Angiography after Cardiac Arrest

***PCI: Percutaneous coronary intervention

⁺ICD: Implantable cardioverter defibrillator

⁺⁺ROSC: Return of spontaneous circulation