Monday, May 29, 2023
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This activity is intended for primary care physicians, cardiologists, critical care specialists, nurses, physician assistants, and other clinicians who treat and manage patients who experience out-of-hospital cardiac arrest.
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Out-of-hospital cardiac arrest is associated with high rates of morbidity and mortality. The authors of the current study note that the rate of good neurological outcomes at discharge after out-of-hospital cardiac arrest is just 2% to 18%.
Most cases of out-of-hospital cardiac arrest are a result of cardiac ischemia. Previous observational research has found that immediate coronary angiography in cases of out-of-hospital cardiac arrest can improve outcomes, but randomized trials of early angiography among patients with out-of-hospital cardiac arrest but no ST elevation on an initial electrocardiogram failed to confirm the benefit of immediate vs delayed coronary angiography.
So who benefits most from immediate coronary angiography for out-of-hospital cardiac arrest? Pareek and colleagues reviewed data from 926 cases of out-of-hospital cardiac arrest in a European registry to answer this question.[1] They found that patients with a baseline high risk for neurological complications did not benefit from immediate vs delayed coronary angiography. In fact, only patients with symptoms of shock but who were in a low-risk group for neurological complications and had ST elevation experienced a higher rate of disability-free survival with immediate vs delayed coronary angiography.
Previous studies have been underpowered to detect a possible benefit of immediate coronary angiography for patients with out-of-hospital cardiac arrest who do not have ST elevation. The current research attempts to address this issue.
Patients successfully resuscitated after an out-of-hospital cardiac arrest who did not have ST-segment elevation on their electrocardiogram did not benefit from emergency coronary angiography in a new randomized clinical trial.
In the EMERGE trial, a strategy of emergency coronary angiography was not found to be better than a strategy of delayed coronary angiography with respect to the 180-day survival rate with no or minimal neurologic sequelae.
The authors note that although the study was underpowered, the results are consistent with previously published studies and do not support routine emergency coronary angiography in survivors of out-of-hospital cardiac arrest without ST elevation.
However, senior author Christian Spaulding, MD, PhD, from the European Hospital Georges Pompidou, Paris, France, believes that some such patients may still benefit from emergency angiography.
"Most patients who have been resuscitated after out-of-hospital cardiac arrest will have neurological damage, which will be the primary cause of death," Dr Spaulding told theheart.org | Medscape Cardiology. "It will not make any difference to these patients if they have a coronary lesion treated. So, going forward, I think we need to look for patients who are likely not to have a high degree of neurological damage and who could still benefit from early angiography."
The EMERGE study was published online in JAMA Cardiology on June 8.[2]
In patients who have suffered an out-of-hospital cardiac arrest with no obvious noncardiac cause such as trauma, it is believed that the cardiac arrest is caused by coronary occlusions, and emergency angiography may be able to improve survival in these patients, Dr Spaulding explained.
In about one third of such patients, the electrocardiogram before hospitalization shows ST elevation, and in this group there is a high probability (around 70%-80%) that there is going to be a coronary occlusion, so these patients are usually taken directly to emergency angiography.
However, in the other two thirds of patients, there is no ST elevation on the electrocardiogram, and in these patients the chances of finding a coronary occlusion are lower (around 25%-35%).
The EMERGE trial was conducted in this latter group without ST elevation.
For the study, which was conducted in 22 French centers, 279 such patients (mean age, 64 years) were randomly assigned to either emergency or delayed (48 to 96 hours) coronary angiography. The mean time delay between randomization and coronary angiography was 0.6 hours in the emergency group and 55.1 hours in the delayed group.
The primary outcome was the 180-day survival rate with minimal neurological damage, defined as a Cerebral Performance Category of 2 or less. This occurred in 34.1% of the emergency angiography group and 30.7% of the delayed angiography group (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.65-1.15; P=.32).
There was also no difference in the overall survival rate at 180 days (36.2% versus 33.3%; HR, 0.86; P=.31) and in secondary outcomes between the 2 groups.
Dr Spaulding noted that 3 other randomized trials in a similar patient population have all shown similar results, with no difference in survival found between patients who have emergency coronary angiography as soon as they are admitted to hospital and those in whom angiography was not performed until a couple of days later.
However, several registry studies in a total of more than 6000 patients have suggested a benefit of immediate angiography in these patients. "So, there is some disconnect here," he said.
Dr Spaulding believes that the reason for this disconnect may be that the registry studies may have included patients with less neurological damage who were more likely to survive and to benefit from having coronary lesions treated promptly.
"Paramedics sometimes make a judgment on which patients may have minimal neurological damage, and this may affect the choice of hospital a patient is taken to, and then the emergency department doctor may again assess whether a patient should go for immediate angiography or not. So, patients in these registry studies who received emergency angiography were likely already preselected to some extent," he suggested.
In contrast, the randomized trials have accepted all patients, so there were probably more with neurological damage. "In our trial, almost 70% of patients were in asystole. These are the ones who [are] the most likely to have neurological damage," he pointed out.
"Because there was such a striking difference in the registry studies, I think there is a group of patients [who] will benefit from immediate emergency coronary angiography, but we have to work out how to select these patients," he commented.
Dr Spaulding noted that a recent registry study published in JACC: Cardiovascular Interventions used a score known as MIRACLE2 (which takes into account various factors including age of patient and type of rhythm on electrocardiogram) and the degree of cardiogenic shock on arrival at hospital, as measured by the SCAI shock score, to define a potential cohort of patients at low risk for neurologic injury who benefit most from immediate coronary angiography.[1]
"In my practice at present, I would advise the emergency team that a young patient who had had resuscitation started quickly, had been defibrillated early, and got to hospital quickly should go for an immediate coronary angiogram. It can't do any harm, and there may be a benefit in such patients," Dr Spaulding added.
The EMERGE study was supported in part by Assistance Publique–Hôpitaux de Paris and the French Ministry of Health through the national Programme Hospitalier de Recherche Clinique. Dr Spaulding has disclosed no relevant financial relationships.
JAMA Card. Published online June 8.
