Should patients with an out-of-hospital cardiac arrest and without an ECG ST-elevation receive immediate coronary angiography- ESC 2026
Immediate coronary angiography did not improve 30-day survival compared with a deferred strategy in patients without an ECG ST-elevation after out-of-hospital cardiac arrest. These were the main findings of the DISCO trial and a meta-analysis presented in a Hot Line session today at ESC Congress 2026.
Acute coronary syndrome is a common cause of out-of-hospital cardiac arrest (OHCA). In patients with OHCA presenting with an ST-elevation on an ECG, immediate coronary angiography to assess artery blockages is recommended, with subsequent percutaneous coronary intervention (PCI) where necessary to restore blood flow. However, evidence for the use of coronary angiography in patients without an ECG ST-elevation is limited.
Lead Investigator of the DISCO trial, Professor Sten Rubertsson from Uppsala University, Sweden, commented, “Current guidelines recommend a deferred rather than an immediate strategy for coronary angiography, based mainly on the neutral results from two medium-sized trials. However, clinical practice varies widely and this may be due to the lack of definitive evidence on hard clinical outcomes. The aim of the large DISCO trial was to determine whether immediate coronary angiography does or does not improve survival in patients after an OHCA without an ST-elevation.”
The trial was conducted in 23 centres in Sweden, Denmark and the Netherlands. Adult unconscious patients with witnessed OHCA, return of spontaneous circulation and without ST-elevation on prehospital or emergency department ECG were included. Patients were randomised (1:1) to immediate coronary angiography (within 120 minutes) or to a deferred strategy in which coronary angiography was intended to be delayed for at least 72 hours. In cases of electrical or haemodynamic instability, coronary angiography could be performed before 72 hours. In the immediate group, PCI was recommended on the presumed culprit lesion, while non-culprit lesions were not to be treated during the acute procedure. A total of 1,006 patients were included who had a mean age of 67 years and around one-quarter were women.
No difference in the primary endpoint of survival at 30 days was observed between immediate and deferred coronary angiography (54.6% vs. 53.6%; hazard ratio [HR] 0.95; 95% confidence interval [CI] 0.74 to 1.21; p=0.67). Similarly, there was no difference between the groups for survival at 180 days. There were also no significant differences in secondary endpoints related to neurological recovery.
“With these results from the largest randomised trial investigating this clinical dilemma, we can now conclusively say that immediate coronary angiography after OHCA does not improve outcomes over a deferred strategy,” stated Professor Rubertsson.
Researchers from Radboud University Medical Centre, Nijmegen, the Netherlands, led by Professor Niels van Royen, conducted an individual patient data meta-analysis of five randomised controlled trials, which included DISCO and involved data from 2,173 patients.2 As presented by Ms Lente Pol, there was no difference in 30-day survival between patients who received immediate coronary angiography and those who did not. “These results show that we can safely delay coronary angiography in patients after OHCA without ST elevation,” she concluded.
