Coronary Angiography After Cardiac Arrest: A Deep Dive for PEARL.

Abstract

HomeCirculationVol. 142, No. 21Coronary Angiography After Cardiac Arrest Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBCoronary Angiography After Cardiac ArrestA Deep Dive for PEARL J.S. Lemkes, MD J.S. LemkesJ.S. Lemkes Jorrit Lemkes, Department of Cardiology, Amsterdam University Medical Center, Location VUmc, De Boelelaan 1117, Amsterdam, The Netherlands. Email E-mail Address: [email protected] https://orcid.org/0000-0003-1005-2544 Department of Cardiology, Amsterdam University Medical Center, Location VUmc, The Netherlands. Search for more papers by this author Originally published23 Nov 2020https://doi.org/10.1161/CIRCULATIONAHA.120.051155Circulation. 2020;142:2013–2015This article is a commentary on the followingRandomized Pilot Clinical Trial of Early Coronary Angiography Versus No Early Coronary Angiography After Cardiac Arrest Without ST-Segment ElevationArticle, see p 2002Despite advances in the fields of resuscitation and intensive care management, the outcome of out-of-hospital cardiac arrest remains poor. Optimal care after out-of-hospital cardiac arrest and successful resuscitation includes targeted temperature management, vital organ support, and treatment of the underlying cause of the arrest. The cause of the arrest is often unclear immediately after the event, in particular in the absence of ST-segment elevation (STE) on ECG. This lack of a definitive diagnosis can lead to uncertainty about the appropriate treatment.Patients who survive cardiac arrest have a high prevalence of coronary artery disease and if myocardial infarction is the cause of the arrest, immediate coronary angiography and percutaneous coronary intervention might improve outcome. Previous observation studies reported a survival benefit of an immediate invasive strategy in patients who were resuscitated from cardiac arrest even in the absence of STE myocardial infarction compared with historical controls.1,2 However, these outcomes might have been an effect of the observational nature of these studies, which may have resulted in selection bias that favored selecting patients who had a presumed better prognosis for immediate angiography.The first large randomized, controlled trial addressing the effect of immediate coronary angiography in patients without STE after cardiac arrest was the COACT study (Coronary Angiography After Cardiac Arrest). The COACT study randomly assigned 552 patients after cardiac arrest to either immediate coronary angiography or delayed coronary angiography after neurologic recovery and found no difference in 90-day survival.3 It has been advocated that these results should be confirmed by additional randomized studies.The international, multicentered, randomized PEARL trial (Early Coronary Angiography Versus Delayed Coronary Angiography),4 reported in this issue, is a pilot study comparing early (<2 hours) coronary angiography versus no early coronary angiography in comatose patients resuscitated from out-of-hospital cardiac arrest without STE. The trial had slow recruitment and inclusion was terminated when 99 of the planned 226 patients were randomized. The study should therefore be considered underpowered. PEARL found no difference in the primary end point (a composite of efficacy and safety measures, including efficacy measures of survival to discharge, favorable neurologic status at discharge, echocardiographic measures of left ventricular ejection fraction >50%, and a normal wall motion score of 16 within 24 hours of admission). Adverse events including rearrest, pulmonary edema on chest x-ray, acute renal dysfunction, bleeding requiring transfusion or intervention, hypotension, and pneumonia were compared between the 2 groups (55.1% versus 46.0%; P=0.64). The trial found no difference in individual efficacy measures or adverse events between the 2 treatment strategies. Although the trial was underpowered, these results are consistent with the COACT findings.Overall survival until hospital discharge in the PEARL trial was ≈50%. This is lower than the 65% overall survival reported in the COACT study. This difference in survival between the 2 studies is most likely the result of a different patient population. Patients with cardiogenic shock and those with a nonshockable arrest rhythm were included in the PEARL trial but not in the COACT study. Time from arrest to return of spontaneous circulation was longer in PEARL compared with COACT. All these patient characteristics are associated with worse outcome.One could argue that the higher-risk population in the PEARL trial was more likely to benefit from an early invasive strategy. This might have been the case, because patients with cardiogenic shock and myocardial infarction are known to have better outcome with early revascularization.5,6 However, a longer time from arrest to return of spontaneous circulation, as observed in the PEARL trial, increases the risk of neurologic injury and death7 and is less likely influenced by the timing of coronary angiography. As in the COACT trial, the majority of nonsurvivors in the PEARL study died of neurologic complications.In the PEARL trial, a culprit lesion, defined as a significant stenosis with unstable features, was identified more often during coronary angiography than in the COACT study (≈45% versus 15%). If an acute coronary syndrome was more frequently the cause of arrest in the PEARL trial, one would assume these patients would benefit more from an early invasive strategy. However, in the absence of STE, it can be difficult to identify a culprit lesion and detecting unstable features of a lesion by coronary angiography can be challenging and somewhat subjective. Despite the increased rate of culprit lesions in PEARL, percutaneous coronary intervention rates in the early invasive arm were comparable between the 2 studies.The outcomes of COACT and PEARL do not support a routine early invasive strategy in patients without STE myocardial infarction after cardiac arrest. Although urgent coronary angiography should be considered in patients who deteriorate clinically and show signs of shock, STE myocardial infarction, or recurrence of ventricular tachycardia, in the majority of patients coronary angiography can be delayed until after neurologic recovery. The question whether routine coronary angiography after neurologic recovery should be part of the workup of patients with cardiac arrest cannot be answered by COACT or PEARL, because routine angiography was intended in all patients in both these studies independently of timing. However, the high incidence of coronary artery disease in these studies seems to justify performing coronary angiography in search for a cause of the arrest and a substrate for therapy.The observations from PEARL illustrate the conundrum we face. How can we select patients for early coronary angiography after cardiac arrest with a high risk of acute coronary syndrome as cause of the arrest but with a low risk of neurologic death? We have no method or score to identify such patients. Although the PEARL trial adds to the understanding of the role of early coronary angiography in patients after out-of-hospital cardiac arrest and without STE myocardial infarction, additional large randomized trials are needed to provide definitive answers. The results of DISCO (Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest), COUPE (Coronariography in Out-of-Hospital Cardiac Arrest), TOMAHAWK (Immediate Unselected Coronary Angiography Versus Delayed Triage in Survivors of Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation), and ARREST (A Randomised Trial of Expedited Transfer to a Cardiac Arrest Centre for Non-ST Elevation Ventricular Fibrillation Out-of-Hospital Cardiac Arrest; Table) are highly anticipated.Table. Ongoing Randomized Trials Comparing Early Coronary Angiography (CAG) With Delayed CAG in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment ElevationTitle and acronymIdentifierCountrySample sizeTreatment randomizationPrimary end pointDISCO (Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest)8NCT02309151Sweden1006CAG as soon as possible vs delayed/selective CAG (>3 days after hospital admission)30-day survivalCOUPE (Coronariography in Out-of-Hospital Cardiac Arrest)NCT02641626Spain166CAG as soon as possible vs CAG after extubation and with a good neurologic prognosisSurvival with good neurologic outcome (CPC 1 or 2) at 30 daysTOMAHAWK (Immediate Unselected Coronary Angiography Versus Delayed Triage in Survivors of Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation)9NCT02750462Germany and Denmark558Immediate CAG vs delayed/selective CAG (>24 h after hospital admission)30-day survivalARREST (A Randomised Trial of Expedited Transfer to a Cardiac Arrest Centre for Non-ST Elevation Ventricular Fibrillation Out-of-Hospital Cardiac Arrest)10ISRCTN96585404United Kingdom860Direct transport to a cardiac arrest center and immediate CAG vs transport to the nearest emergency department30-day mortalityCPC indicates Cerebral Performance Category.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circJorrit Lemkes, Department of Cardiology, Amsterdam University Medical Center, Location VUmc, De Boelelaan 1117, Amsterdam, The Netherlands. Email j.[email protected]nl