Immediate coronary angiography for resuscitated cardiac arrest patients without signs of heart attack doesn't help, the COACT trial showed at the in New Orleans.
In this exclusive ľֱ video, , of Duke University School of Medicine, and , of NewYork-Presbyterian/Columbia University, discuss the trial and take-home message.
Following is a transcript of their remarks:
Kirtane: The COACT trial is a pretty important trial for interventional cardiologists because oftentimes we get called from the emergency room or even out of the hospital for patients that have a cardiac arrest. Typically, most interventionalists have challenged themselves to try to take care of these patients because many times those patients can have a lot of benefit from what we do, but there are many patients that might not benefit as well because of the cause of their arrest and the fact that they may have anoxic brain injury.
The idea of this trial was to sort out whether taking those patients to the cath lab and doing an angiogram was associated with a difference of survival than if we sort of delayed the angiography, which is what often happens in these circumstances. Notably, they excluded patients with STEMI [ST-elevation myocardial infarction] or VF [ventricular fibrillation] or some clear reason to go to the cath lab.
What the trial showed is there's really no difference in outcomes with an earlier strategy versus a delayed strategy. Interestingly, people did have disease. They had a lot of multivessel disease, and 40% of patients got revascularized with the early strategy of revascularization, but delaying the revascularization didn't seem to be associated with any differential increase in mortality. In some cases, the most sick patients crossed over and had angiography, but that wasn't really a lot of patients.
Ohman: The COACT trial is a randomized trial in patients without ST elevation, very important, that have cardiac arrest, resuscitation, return of spontaneous circulation, and then are brought to an emergency department and are unconscious. The question is should you or should you not take those patients to revascularization and cardiac catheterization? In ST elevation, that's a different group, there's some evidence that you should. This is the first randomized trial that actually is testing the question of should you take this non-ST elevation cohort?
The short answer is no. In fact, in this trial, there was no effect on 90-day survival, and so essentially, if you go to the cath lab to answer a clinical question, that might be reasonable, but certainly it's not going to affect survival. Therefore, we probably shouldn't do it unless there's a very compelling reason.
The compelling reasons could be cardiogenic shock or something else that would affect mortality. This trial was too small to address these sorts of subgroups, but in general, I would say that this will simplify the matters for us because this comes up all the time in our practice. It's a fairly large cohort of patients, and it would appear, although the authors of this study couldn't address this really, that this is an electrical issue, because there was no culprit vessel in the majority of the cases. That helps us a lot for the future.
Kirtane: I think the take-home for interventionalists is that you can probably sleep a little bit more or at least go back to sleep when they call you as long as the patient doesn't make a clear indication for coming to the cath lab like STEMI, VT [ventricular tachycardia]/VF, or perhaps even just progressive cardiogenic shock where they might need some other stabilization.