COACT

Incomplete

Lemkes JS, et al. "Coronary angiography after cardiac arrest without ST-segment elevation". The New England Journal of Medicine. 2019. 380(15):1397-1407.
PubMed • Full text • PDF

Clinical Question

In patients with out of hospital cardiac arrest (OHCA) and successful resuscitation and absence of ST elevation MI, is survival better with immediate or delayed angiography?

Major Points

Several small and large randomized trials in diabetics had previously suggested a sizable benefit of tight glycemic control in reducing cardiovascular risk. The ACCORD trial was the largest study of its kind and demonstrated that not only does euglycemia (ie, HbA1c <6%) not reduce cardiovascular risk, it also is associated with a trend towards increased mortality.

Design

• Multicenter, open-label, parallel-group, randomized, controlled trial
• N= 552
  • Immediate angiography (n= 273)
  • Delayed angiography (n= 265)
• Setting: 19 centers in the Nederlands
• Enrollment: January 2015 to June 2018
• Follow-up: 90 days
• Analysis: Intention-to-treat
• Primary outcome: 90 day survival

Population

Inclusion Criteria

• Age > 18
• Out of Hospital Cardiac Arrest with ROSC (GSC < 8)
• Comatose
• Ventricular fibrillation or ventricular tachycardia as initial arrest rhythm

Exclusion Criteria

• Signs of STEMI on the ECG at the emergency department (including new LBBB or

isolated ST depression in V1-V3 due to an true posterior infarct).

• Hemodynamic instability unresponsive to medical therapy. Defined as a prolonged (>30 min) systolic blood pressure < 100 mm Hg at the time of screening.
• An obvious or suspected non cardiac aetiology of the cardiac arrest.
• A known severe renal dysfunction. (GRF< 30 ml/min)
• Obvious or suspected pregnancy
• Suspected or confirmed acute intracranial bleeding
• Suspected or confirmed acute stroke
• Known limitations in therapy or DO Not Resuscitate-order.
• Known pre-arrest Cerebral Performance Category 3 or 4
• >4 hours (240 min from ROSC to screening)
• Refractory ventricular arrhythmia
• Known inability to complete 90 day follow up*

Baseline Characteristics

Immediate Angiography vs Delayed Angiography

• Mean age: 65.7 v 64.9
• Male: 81.7 v 76.2%
• HTN 48.7 v 47.5%
• Previous MI 26.7 v 28.7%
• Previous CABG 12.8 v 9.1%
• Previous PCI 16.9 v 22.7%
• Previous CAD 36.8 v 36.2%
• Prior CVA 7.0 v 5.7%
• DM 20.2 v 16.6%
• Current smoker 20.1 v 26.9%
• HLD 25.9 v 29.7%
• PAD 5.9 v 8.7%
• Arrest witnessed 79.9 v 76.6%
• Time to BLS 2 v 2 minutes
• Time to ROSC 15 v 15
• Ischemic ECG
• Mean GCS at admision 3 v 3
• APACHE IV score 107 v 105
• Baseline labs
  • pH 7.2 v 7.2
  • Lactic acid 5.3 v 4.9
  • Bicarbonate 19.4 v 19.0
  • Base excess -7.4 v -7.7
  • pO2 14.7 v 15.3
  • Mixed venous spO2 94 v 94%
  • Cr umol/L 102 v 101
  • CK ug/L 6 v 6.3
  • Troponin T ug/L 0.044 v 0.053

Interventions

Randomized to immediate angiography or delayed angiography

Outcomes

Comparisons are immediate angiography vs. delayed angiography.

Primary Outcomes

Survival at 90 days

64.5% vs. 67.2%% (OR 0.89; 95% CI 0.62-1.27)

Secondary Outcomes

Survival with good cerebral performance or mild of moderate disability

62.9% vs. 64.4% (OR 0.94; 95% CI 0.66-1.31)

CPC score at 90 days

1 57.7% vs. 60.2%

2 5.1% vs. 4.2$, OR 1.29 (0.56-2.92)

3 1.5% vs. 1.9%, OR 0.81 (0.21-3.07)

4 0% vs. 0.8%

5 35.7% vs. 68.7%, OR 0.85 (0.60-1.22)

Survival until hospital discharge 65.2% vs. 68.7%, OR 0.85 (0.60-1.22)

GCS score

Median

Geometric mean

CPC Score

TIMI major bleeding

Recurrence of ventricular tachycardia resulting in defibrillation or electrical cardioversion

Creatinine Kinase

Median AUV

Geometric mean

Creatinine Kinase MB

Median

Geometric mean

Troponin T

Median

Geometric mean

Troponin I

Median

Geometric mean

AKIN Stage

Need for renal replacement therapy

Time to target temperature

Median

Geometric mean

Time to hypothermia

Median

Geometric mean

Time to normothermia

Median

Geometric mean

Duration of intortopic or catecholamine support

Median

Geometric mean

Markers of shock

Duration of mechanical ventilation

Median

Geometric mean

Funding

Netherlands Heart Institute, Biotronik, and AstraZeneca.