Coronary angiography in out-of-hospital cardiac arrest : why, when and for whom?

Study I. A national observational retrospective study, evaluating the effect on survival of early coronary angiography vs. no early coronary angiography in witnessed, unconscious OHCA patients with shockable rhythm and without ST-elevation on the first ECG. Unadjusted 30-day survival in the early-angiography group was 65%, compared with 52% in the no-early-angiography group. The adjusted OR for 30-day survival was 1.42 for early angiography (95% CI 1.00-2.02, p=0.048). The adjusted HR for one-year survival was 1.35 for early angiography (95% CI 1.04-1.77, p=0.03).

Study II. An open-label, prospective, randomized, national multicenter clinical study in OHCA patients carried out to assess feasibility and safety aspects in a strategy of coronary angiography within 120 minutes from first medical contact versus coronary angiography potentially performed at a later stage. Among 79 randomized patients (from 2015 to 2017), 39 were randomized to immediate coronary angiography and 40 to standard-of-care treatment. The median time from EMS arrival to coronary angiography was 135 minutes in the immediate-angiography group. A culprit lesion was found in 14/38 (36.8 %) patients randomized to immediate coronary angiography and PCI was performed in all these patients. In patients randomized to standard of care treatment 6/40 (15%) underwent coronary angiography before the stipulated three days.

Study III. A retrospective, descriptive, single-center study, assessing the use of Focused Cardiac Ultrasound (FOCUS) in cardiac-arrest patients with ROSC and without ST-elevations on the ECG. In total, FOCUS was performed in 237 (182 OHCA and 55 in-hospital cardiac arrest) patients. FOCUS findings had an impact on management and led to further immediate diagnostic measures in 52 (21.9%) patients.

Study IV. A sub-study of Study II carried out to compare post-resuscitation myocardial function in the two randomized groups. In the immediate angiography group, median left-ventricle ejection fraction (LVEF) at 24 hours was 47% (Q1-Q3; 30-55) compared with 46% (Q1-Q3; 35-55) in the standard-of-care group. The peak Troponin-T level during the first 24 hours was 362 ng/L (Q1-Q3; 174-2020) in the immediate-angiography group compared with 377 ng/L (Q1-Q3;205-1078) in the standard-of-care group.

Conclusions: In a Swedish OHCA population with shockable rhythm without ST-elevation, early coronary angiography may be associated with improved short- and long-term survival. Randomizing OHCA patients without ST-elevation to a strategy of immediate coronary angiography was feasible. No significant safety issues were observed. No differences in post-resuscitation myocardial dysfunction parameters between the two groups were found. Post-resuscitation assessment could include FOCUS as an adjunctive diagnostic measure shortly after ROSC.

List of scientific papers

I. Elfwén L, Lagedal R, James S, Jonsson M, Jensen U, Ringh M, Claesson A, Oldgren J, Herlitz J, Rubertsson S, Nordberg P. Coronary angiography in out-of-hospital cardiac arrest without ST elevation on ECG—Short- and long-term survival. Am Heart J. 2018; 200:90-95.
https://doi.org/10.1016/j.ahj.2018.03.009

II. Elfwén L, Lagedal R, Nordberg P, James S, Oldgren J, Böhm F, Lundgren P, Rylander C, van der Linden J, Hollenberg J, Erlinge D, Cronberg T, Jensen U, Friberg H, Lilja G, Larsson IM, Wallin E, Rubertsson S, Svensson L. Direct or subacute coronary angiography in out-of-hospital cardiac arrest (DISCO)-An initial pilot study of a randomized clinical trial. Resuscitation. 2019; 139:253-261.
https://doi.org/10.1016/j.resuscitation.2019.04.027

III. Elfwén L, Hildebrand K, Schierbeck S, Sundqvist M, Ringh M, Claesson A, Olsson J, Nordberg P. Focused cardiac ultrasound after return of spontaneous circulation in cardiac-arrest patients. Resuscitation. 2019; 142:16-22.
https://doi.org/10.1016/j.resuscitation.2019.06.282

IV. Elfwén L, Lagedal R, Sten Rubertsson, Stefan James, Jonas Oldgren, Jens Olsson, Jacob Hollenberg, Ulf Jensen, Mattias Ringh, Leif Svensson, Per Nordberg. Post-resuscitation myocardial dysfunction in out-of-hospital cardiac arrest patients randomized to immediate coronary angiography versus standard of care. [Accepted]
https://doi.org/10.1016/j.ijcha.2020.100483