Abstract Body (Do not enter title and authors here): Hypothesis and Purpose: Ischemic heart disease is a common cause of cardiac arrest. For patients without ST-segment elevation after return of spontaneous circulation (ROSC), the Coronary Angiography after Cardiac Arrest (COACT) trial was the first randomized trial that investigated the benefit of immediate versus delayed coronary angiography with subsequent PCI if needed. It found no difference in 90-day survival. The long-term impact on survival of the two treatment strategies remains uncertain.
Research Questions: To investigate the impact on survival of immediate vs. delayed coronary angiography in out-of-hospital cardiac arrest (OHCA) patients with an initial shockable rhythm and no ST-segment elevation on the first ECG after ROSC obtained in the emergency department
Study design and methods: The COACT trial was an investigator-initiated, randomized, open-label, multi-center study that investigated the benefit of immediate versus delayed coronary angiography in successfully resuscitated OHCA without ST-segment elevation. During the study period from January 8, 2015 to July 17, 2018, patients that were successfully resuscitated after OHCA without ST-segment elevation were enrolled in the trial at 19 participating Dutch centers.
Outcomes: At five-year follow-up, data from 514/552 (93.1%) patients were available. Of these patients, 261 (50.8%) were assigned to immediate angiography, and 253 (49.2%) to a delayed strategy. Baseline characteristics were similar across the two treatment groups. Five years after the index hospitalization, 143 (54.8%) patients were alive in the immediate angiography group and 131 (51.8%) patients were alive in the delayed angiography group (HR 0.95; 95% CI, 0.74 – 1.23) P log-rank=0.72). In the landmark analysis, hazard ratios for death to 90 days and >90 days follow-up periods were 1.11; 95 % CI 0.84 – 1.49 (log-rank P=0.46) and 0.56; 95% CI 0.32 – 0.97 (log-rank P=0.04). A time-dependent interaction term between early (0-90 days) and late (>90 days) hazard ratios was p=0.03.
Conclusion: At five years after the arrest, survival was comparable between the immediate and delayed angiography strategies, with overall neutral treatment effects. A significant late survival difference emerged beyond 90 days in favor of the immediate group. While this may suggest a potential long-term benefit, its clinical relevance remains uncertain and should be interpreted with caution in the context of the overall neutral long-term outcomes.