Emergency angiography for cardiac arrest without ST elevation?

Out-of-hospital patients who did not have an ST-section elevation on the ECG and did not benefit from emergency coronary angiography were successfully resuscitated in a new randomized clinical trial.

In the EMERGE trial, no emergency coronary angiography strategy was found better than a delayed coronary angiography strategy with respect to 180-day survival with no or minimal neurological sequelae.

The authors note that although the study is weak, the results are consistent with previously published studies and do not support routine emergency coronary angiography of out-of-hospital cardiac arrest survivors without ST elevation.

But lead author, Christian Spaulding, MD, PhD, European Hospital Georges Pompidou, Paris, France, believes that some of these patients may still benefit from emergency angiography.

Dr. Christian Spaulding

“Most patients who are resuscitated after cardiac arrest in hospital will have neurological damage that will be the leading cause of death,” Spaulding said. theheart.org | Medscape Heart. “It wouldn’t make any difference to these patients if they were treated for a coronary lesion. So, going forward, I think we need to look for patients who likely don’t have a high degree of neurological damage and who can still benefit from early angiography.”

The EMERGE study has been published online at heart gamma On June 8.

Spaulding explained that in patients who have experienced cardiac arrest outside the hospital with no obvious cardiac cause such as shock, cardiac arrest is thought to be due to coronary artery blockage, and emergency angiography may be able to improve survival in these patients. .

In about a third of these patients, the pre-hospital ECG shows ST elevation, and in this group, there is a high probability (about 70% to 80%) of coronary embolism, so these patients are usually taken directly to emergency angiography .

But in the other two-thirds of patients, there is no ST elevation on the electrocardiogram, and in these patients the chances of detecting a coronary artery blockage are lower (about 25% to 35%).

The EMERGE trial was conducted in this latter group without ST elevation.

For the study, which was conducted in 22 French centres, 279 patients (median age, 64 years) were randomized 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 late group.

The primary outcome was a 180-day survival rate with minimal neurological damage, defined as cerebral performance class 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; s = .32).

There was also no difference in the overall survival rate at 180 days (36.2% vs. 33.3%; heart rate 0.86; s = .31) and in secondary outcomes between the two groups.

Spaulding noted that three other randomized trials in a similar group of patients all showed similar results, with no difference in survival between patients who underwent emergency coronary angiography once admitted to hospital and those who did not have angiography until a couple. . after few days.

However, several enrollment studies in a total of more than 6000 patients suggested the benefit of immediate angiography in these patients. “So, there’s some disconnect here,” he said.

Spaulding believes that the reason for this disconnect may be that the enrollment studies may have included patients with less neurological damage, so they are more likely to survive and benefit from treatment of coronary lesions immediately.

Paramedics sometimes make a judgment about patients who may have minimal neurological damage and this may influence the choice of hospital to which the patient is taken, after which the emergency department physician may again assess whether the patient should go for an angiogram right away. or not. Therefore, it is likely that patients in these enrollment studies who received emergency angiography were somewhat pre-selected.”

In contrast, randomized trials accepted all patients, so there may have been more neurological damage. “In our experience, approximately 70% of patients were in asystole [are] Most likely to have neurological damage.”

“Because there is such a striking difference in the enrollment studies, I think there is a group of patients [who] He would benefit from urgent coronary angiography, but we have to figure out how to select these patients.”

Spaulding noted that a recent registry study published in JACC: Cardiovascular Interventions Use a score known as MIRACLE2 (which takes into account various factors including the patient’s age and type of rhythm on the electrocardiogram) and the degree of cardiogenic shock upon arrival at hospital as measured by the SCAI shock score to identify a potential cohort of patients at low risk of neurological injury who They benefit most from immediate coronary angiography.

“In my practice at the moment, I would like to advise the emergency team that a young patient who had CPR started quickly, had defibrillation removed early and arrived at hospital quickly, should have a coronary angiography immediately. This cannot cause Any harm there may be beneficial to such patients.”

gamma card. Posted online June 8. full text.

The EMERGE study was supported in part by Assistance Publique-Hôpitaux de Paris and the French Ministry of Health, through the National Program Hospitalier de Recherche Clinic. Spaulding does not state any relevant financial relationships.

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