Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest

Abstract

IMPORTANCE Although an emergency coronary angiogram (CAG) is recommended for patients who experience an out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the postresuscitation electrocardiogram (ECG), this strategy is still debated in patients without ST-segment elevation. OBJECTIVE To assess the 180-day survival rate with Cerebral Performance Category (CPC) 1 or 2 of patients who experience an OHCA without ST-segment elevation on ECG and undergo emergency CAG vs delayed CAG. DESIGN, SETTING, AND PARTICIPANTS The Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) trial randomly assigned survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG in 22 French centers.

Immediate coronary angiography in patients with out-of-hospital cardiac arrest without ST-segment elevation: a meta-analysis of randomized trials

“…We identified six eligible RCTs including a total of 1589 patients for the primary end point [3][4][5][6][7][8] that fulfilled inclusion criteria (Fig. 1).…”

“…Since one study 8 did not report the neurological outcome, we analyzed five eligible RCTs including a total of 1510 patients for this end point. [3][4][5][6][7] The patients who underwent immediate coronary angiography had similar allcause mortality (Fig. 2a) compared with those who did not, without heterogeneity [RR (95% CI): 1.04 (0.94-1.15),…”

“…The primary end point was all-cause mortality within 180 days of arrest. The secondary end point was the poor neurological outcome (as measured by Cerebral Performance Category of [3][4][5] and the rate of percutaneous coronary intervention (PCI). The random-effects model was used to calculate the risk ratios (RR) and confidence intervals (CI).…”

“…9 However, the analyses utilized both observational studies and RCTs, resulting in high heterogeneity, and did not include recent RCTs with large populations (TOMAHAWK and EMERGE trials). 3,4 Thus, the current meta-analysis consisting of only RCTs and including the largest RCTs would fill an evidence gap, demonstrating no clear benefit of immediate coronary angiography for OHCA patients without STE.…”

Improved outcomes in survivors of cardiac arrest qualified for early coronary angiography: A single tertiary center study

“…The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for relative risk (RR) of 1.16 (95% CI, 1.00-1.34). In the recently published EMERGE trial [25] which evaluated the 180-day survival rate with CPC 1 or 2 of patients who experienced an OHCA without STE on ECG and underwent emergency CA vs. delayed CA, there was no difference in the overall survival rate (emergency CA, 36.2% [51 of 141] vs. delayed CA, 33.3% [46 of 138]; HR 0.86; 95% CI, 0.64-1.15; P = 0.31) or in secondary outcomes between the 2 groups. Patients' populations in the above-cited studies were significantly different from ours and included only subjects without signs of STEMI.…”