Is emergency coronary angiogram required in cardiac arrest patients without ST-segment elevation?

France: In patients who experienced an out-of-hospital cardiac arrest (OHCA) without ST-segment elevation on electrocardiogram (ECG), an emergency coronary angiogram (CAG) method was no better than a delayed CAG strategy in terms of 180-day survival rate and minimum neurologic sequelae, says an article published in the Journal of American Medical Association-Cardiology.

Although an immediate coronary angiography is suggested for individuals who have an out-of-hospital cardiac arrest with ST-segment elevation on the post-resuscitation ECG, such a method is still being contested in patients who do not have ST-segment elevation. As a result, Caroline Hauw-Berlemont and colleagues undertook this study to compare the 180-day survival rate with Cerebral Performance Category (CPC) in one or two participants who have an OHCA without ST-segment elevation on ECG and have emergency CAG vs delayed CAG.

The Emergency versus Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) study, conducted in 22 French hospitals, randomly allocated survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG. From January 19, 2017, through November 23, 2020, the trial was held. The data was examined from November 24, 2020, to July 30, 2021.

The 180-day survival rate with a CPC of 2 or below was the main outcome. Secondary endpoints included the occurrence of shock, ventricular tachycardia, and/or fibrillation within 48 hours, the change in left ventricular ejection fraction between baseline and 180 days, the CPC scale at ICU discharge and day 90, the chance of survival, and the length of stay in the hospital.

The key findings of this study were as follows:

1. There were 279 individuals in the immediate CAG group and 138 (49.5%) in the delayed CAG group.

2. The mean (SD) time delay between randomized and CAG in the emergency CAG group was 0.6 (3.7) hours and 55.1 (37.2) hours in the delayed CAG group.

3. The emergency CAG group had a 34.1% (47 of 141) 180-day survival rate while the delayed CAG group had a 30.7% (42 of 138) survival rate.

4. There was no difference between the two groups in terms of overall survival at 180 days or secondary outcomes.

In conclusion, the authors found that the findings of this study were consistent with prior research and do not justify immediate CAG in OHCA patients without ST elevation.

Reference:

Hauw-Berlemont C, Lamhaut L, Diehl J, et al. Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial. JAMA Cardiol. Published online June 08, 2022. doi:10.1001/jamacardio.2022.1416