Immediate vs Delayed Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation: 5-Year Outcomes From the COACT Randomized Trial.

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a major global health issue. For patients without ST-segment elevation after return of spontaneous circulation, the COACT (Coronary Angiography After Cardiac Arrest) trial was the first randomized trial that investigated the benefit of immediate vs delayed coronary angiography with subsequent percutaneous coronary intervention if needed. No difference in 90-day survival was found. The long-term impact on survival of the 2 treatment strategies remains uncertain.

OBJECTIVES

The aim of this study was to investigate the 5-year impact on survival of immediate vs delayed coronary angiography in OHCA patients with an initial shockable rhythm and no ST-segment elevation on initial electrocardiography after return of spontaneous circulation.

METHODS

The COACT trial was a randomized, open-label, multicenter study comparing immediate vs delayed coronary angiography in patients resuscitated from OHCA without ST-segment elevation. Nineteen Dutch centers enrolled patients, and 5-year follow-up was obtained via structured telephone interviews. Secondary endpoints included myocardial infarction, repeat revascularization, heart failure-related hospitalizations, and implantable cardioverter-defibrillator shocks.

RESULTS

At 5-year follow-up, data from 514 of 552 patients (93.1%) were available. Of these patients, 261 (50.8%) were assigned to immediate angiography and 253 (49.2%) to a delayed strategy. Baseline characteristics were similar across the 2 treatment groups. Five years after the index hospitalization, 143 patients (54.8%) were alive in the immediate angiography group, and 131 patients (51.8%) were alive in the delayed angiography group (HR: 0.95; 95% CI: 0.74-1.23; log-rank P = 072). In a nonprespecified and exploratory landmark analysis, HRs for death to 90 days and >90 days were 1.11 (95% CI: 0.84-1.49; log-rank P = 0.46) and 0.56 (95% CI: 0.32-0.97; log-rank P = 0.04). Rates of myocardial infarction, heart failure-related hospitalization, and revascularization were low and did not differ between groups.

CONCLUSIONS

At 5 years, survival was comparable between immediate and delayed angiography, with no clear benefit or harm. A late survival benefit appeared after 90 days, though its clinical significance remains uncertain and most likely is due to chance. (Coronary Angiography After Cardiac Arrest [COACT]; NTR4973).