Caroline Hauw-Berlemont1, Lionel Lamhaut2,3,4, Jean-Luc Diehl1,5, Christophe Andreotti6, Olivier Varenne7, Pierre Leroux8, Jean-Baptiste Lascarrou9, Patrice Guerin10, Thomas Loeb11, Eric Roupie12, Cédric Daubin13, Farzin Beygui14, Florence Boissier15, Nicolas Marjanovic16, Luc Christiaens17, Aurélie Vilfaillot18, Sophie Glippa18, Juliette Djadi Prat18, Gilles Chatellier18, Alain Cariou19, Christian Spaulding20. 1. Medical Intensive Care Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France. 2. Paris Cité University, Paris, France. 3. Service d'Aide Médicale D'Urgence 75, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France. 4. INSERM U970; Paris Cardiovascular Research Centre, Paris, France. 5. INSERM Unité Mixte de Recherche-S1140, Paris Cité University, Paris, France. 6. Service Mobile d'Urgence et de Réanimation, Emergency Department Cochin Hôtel Dieu, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France. 7. Interventional Cardiology, Department of Cardiology, Groupe Hospitalier Cochin-Saint Vincent de Paul-Hôtel Dieu, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France. 8. Service d'Aide Médicale d' Urgence 44, University Hospital of Nantes, Nantes, France. 9. Medical Intensive Care Unit, University Hospital of Nantes, Nantes, France. 10. Unité d'Hémodynamique, L'Institut du Thorax, University Hospital of Nantes, Nantes, France. 11. Service d'Aide Médicale d'Urgence 92, Hôpitaux Universitaires Paris-Saclay, Site Raymond Poincaré, Garches, France. 12. Service d'Aide Médicale d'Urgence 14, University Hospital of Caen, Caen, France. 13. Medical Intensive Care Unit, University Hospital of Caen, Caen, France. 14. Department of Cardiology, University Hospital of Caen, Caen, France. 15. Medical Intensive Care Unit, University Hospital of Poitiers, INSERM CIC 1402, Poitiers University, Poitiers, France. 16. Service d'Aide Médicale d'Urgence 86, University of Poitiers, Poitiers, France. 17. Cardiology Department Poitiers University Hospital, University of Poitiers, Poitiers, France. 18. INSERM CIC1418 and Département d'Informatique, Biostatistique et Santé Publique, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France. 19. Medical Intensive Care Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, France. 20. Department of Cardiology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Sudden Cardiac Death Expert Center, INSERM U 971, PARCC, Paris, France.
Abstract
Importance: Although an emergency coronary angiogram (CAG) is recommended for patients who experience an out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the postresuscitation electrocardiogram (ECG), this strategy is still debated in patients without ST-segment elevation. Objective: To assess the 180-day survival rate with Cerebral Performance Category (CPC) 1 or 2 of patients who experience an OHCA without ST-segment elevation on ECG and undergo emergency CAG vs delayed CAG. Design, Setting, and Participants: The Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) trial randomly assigned survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG in 22 French centers. The trial took place from January 19, 2017, to November 23, 2020. Data were analyzed from November 24, 2020, to July 30, 2021. Main Outcomes and Measures: The primary outcome was the 180-day survival rate with CPC of 2 or less. The secondary end points were occurrence of shock, ventricular tachycardia, and/or fibrillation within 48 hours, change in left ventricular ejection fraction between baseline and 180 days, CPC scale at intensive care unit discharge and day 90, survival rate, and hospital length of stay. Results: A total of 279 patients (mean [SD] age, 64.7 [14.6] years; 195 men [69.9%]) were enrolled, with 141 (50.5%) in the emergency CAG group and 138 (49.5%) in the delayed CAG group. The study was underpowered. The mean (SD) time delay between randomization and CAG was 0.6 (3.7) hours in the emergency CAG group and 55.1 (37.2) hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (hazard ratio [HR], 0.87; 95% CI, 0.65-1.15; P = .32). There was no difference in the overall survival rate at 180 days (emergency CAG, 36.2% [51 of 141] vs delayed CAG, 33.3% [46 of 138]; HR, 0.86; 95% CI, 0.64-1.15; P = .31) and in secondary outcomes between the 2 groups. Conclusions and Relevance: In this randomized clinical trial, for patients who experience an OHCA without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequelae. Trial Registration: ClinicalTrials.gov Identifier: NCT02876458.
Importance: Although an emergency coronary angiogram (CAG) is recommended for patients who experience an out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the postresuscitation electrocardiogram (ECG), this strategy is still debated in patients without ST-segment elevation. Objective: To assess the 180-day survival rate with Cerebral Performance Category (CPC) 1 or 2 of patients who experience an OHCA without ST-segment elevation on ECG and undergo emergency CAG vs delayed CAG. Design, Setting, and Participants: The Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest (EMERGE) trial randomly assigned survivors of an OHCA without ST-segment elevation on ECG to either emergency or delayed (48 to 96 hours) CAG in 22 French centers. The trial took place from January 19, 2017, to November 23, 2020. Data were analyzed from November 24, 2020, to July 30, 2021. Main Outcomes and Measures: The primary outcome was the 180-day survival rate with CPC of 2 or less. The secondary end points were occurrence of shock, ventricular tachycardia, and/or fibrillation within 48 hours, change in left ventricular ejection fraction between baseline and 180 days, CPC scale at intensive care unit discharge and day 90, survival rate, and hospital length of stay. Results: A total of 279 patients (mean [SD] age, 64.7 [14.6] years; 195 men [69.9%]) were enrolled, with 141 (50.5%) in the emergency CAG group and 138 (49.5%) in the delayed CAG group. The study was underpowered. The mean (SD) time delay between randomization and CAG was 0.6 (3.7) hours in the emergency CAG group and 55.1 (37.2) hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (hazard ratio [HR], 0.87; 95% CI, 0.65-1.15; P = .32). There was no difference in the overall survival rate at 180 days (emergency CAG, 36.2% [51 of 141] vs delayed CAG, 33.3% [46 of 138]; HR, 0.86; 95% CI, 0.64-1.15; P = .31) and in secondary outcomes between the 2 groups. Conclusions and Relevance: In this randomized clinical trial, for patients who experience an OHCA without ST-segment elevation on ECG, a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and minimal neurologic sequelae. Trial Registration: ClinicalTrials.gov Identifier: NCT02876458.
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