心脏骤停后无 ST 段抬高的冠状动脉造影术。
Coronary Angiography after Cardiac Arrest without ST-Segment Elevation.
机构信息
From the Departments of Cardiology (J.S.L., G.N.J., N.W.H., N.R.), Intensive Care Medicine (P.W.G.E., H.M.O.-S.), and Epidemiology and Biostatistics (P.M.V.), Amsterdam University Medical Center VUmc, the Departments of Cardiology (J.P.H.) and Intensive Care Medicine (A.P.J.V.), Amsterdam University Medical Center AMC, and the Departments of Cardiology (M.A.V.) and Intensive Care Medicine (B.B.), Onze Lieve Vrouwe Gasthuis, Amsterdam, the Thorax Center, Erasmus Medical Center (L.S.D.J., E.A.D.), and the Departments of Cardiology (G.J.V.) and Intensive Care Medicine (B.J.W.E.), Maasstad Hospital, Rotterdam, the Departments of Cardiology (M. Meuwissen) and Intensive Care Medicine (T.A.R.), Amphia Hospital, Breda, the Departments of Cardiology (H.A.B.) and Intensive Care Medicine (M.J.B.), Rijnstate Hospital, Arnhem, the Departments of Cardiology (G.B.B.) and Intensive Care Medicine (R.B.), Haga Hospital, and the Department of Cardiology, Haaglanden Medical Center (P.V.O.), The Hague, the Departments of Cardiology (P.H.) and Intensive Care Medicine (I.C.C.H.), University of Groningen, Groningen, the Departments of Cardiology (M.V.) and Intensive Care Medicine (J.J.H.), University Medical Center Utrecht, Utrecht, the Departments of Intensive Care Medicine (A.B.) and Cardiology (M.S.), Medisch Spectrum Twente, Enschede, the Departments of Cardiology (C.C., N.R.) and Intensive Care Medicine (H.H.), Radboud University Medical Center, Nijmegen, the Departments of Cardiology (T.A.C.M.H.) and Intensive Care Medicine (W.R.), Noordwest Ziekenhuisgroep, Alkmaar, the Departments of Intensive Care Medicine (T.S.R.D.) and Cardiology (H.J.G.M.C.), Maastricht University Medical Center, Maastricht, the Department of Cardiology, Scheper Hospital, Emmen (G.A.J.J.), the Department of Cardiology, Isala Hospital, Zwolle (M.T.M.G.), the Department of Cardiology, Tergooi Hospital, Blaricum (K.P.), and the Department of Cardiology, Elisabeth-Tweesteden Hospital, Tilburg (M. Magro) - all in the Netherlands.
出版信息
N Engl J Med. 2019 Apr 11;380(15):1397-1407. doi: 10.1056/NEJMoa1816897. Epub 2019 Mar 18.
BACKGROUND
Ischemic heart disease is a major cause of out-of-hospital cardiac arrest. The role of immediate coronary angiography and percutaneous coronary intervention (PCI) in the treatment of patients who have been successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) remains uncertain.
METHODS
In this multicenter trial, we randomly assigned 552 patients who had cardiac arrest without signs of STEMI to undergo immediate coronary angiography or coronary angiography that was delayed until after neurologic recovery. All patients underwent PCI if indicated. The primary end point was survival at 90 days. Secondary end points included survival at 90 days with good cerebral performance or mild or moderate disability, myocardial injury, duration of catecholamine support, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, major bleeding, occurrence of acute kidney injury, need for renal-replacement therapy, time to target temperature, and neurologic status at discharge from the intensive care unit.
RESULTS
At 90 days, 176 of 273 patients (64.5%) in the immediate angiography group and 178 of 265 patients (67.2%) in the delayed angiography group were alive (odds ratio, 0.89; 95% confidence interval [CI], 0.62 to 1.27; P = 0.51). The median time to target temperature was 5.4 hours in the immediate angiography group and 4.7 hours in the delayed angiography group (ratio of geometric means, 1.19; 95% CI, 1.04 to 1.36). No significant differences between the groups were found in the remaining secondary end points.
CONCLUSIONS
Among patients who had been successfully resuscitated after out-of-hospital cardiac arrest and had no signs of STEMI, a strategy of immediate angiography was not found to be better than a strategy of delayed angiography with respect to overall survival at 90 days. (Funded by the Netherlands Heart Institute and others; COACT Netherlands Trial Register number, NTR4973.).
背景
缺血性心脏病是院外心脏骤停的主要原因。对于没有 ST 段抬高型心肌梗死（STEMI）迹象的心脏骤停后成功复苏的患者，立即进行冠状动脉造影和经皮冠状动脉介入治疗（PCI）的作用尚不确定。
方法
在这项多中心试验中，我们将 552 名无 STEMI 迹象的心脏骤停患者随机分为立即进行冠状动脉造影组或延迟至神经功能恢复后进行冠状动脉造影组。所有患者均进行 PCI 治疗。主要终点是 90 天的存活率。次要终点包括 90 天的存活率、良好的神经功能或轻度至中度残疾、心肌损伤、儿茶酚胺支持时间、休克标志物、室性心动过速复发、机械通气时间、大出血、急性肾损伤的发生、需要肾脏替代治疗、目标体温时间和重症监护病房出院时的神经状态。
结果
在 90 天时，立即造影组 273 例患者中有 176 例（64.5%）存活，延迟造影组 265 例患者中有 178 例（67.2%）存活（比值比，0.89；95%置信区间[CI]，0.62 至 1.27；P=0.51）。立即造影组达到目标体温的中位时间为 5.4 小时，延迟造影组为 4.7 小时（几何均数比，1.19；95%CI，1.04 至 1.36）。两组在其余次要终点方面无显著差异。
结论
在院外心脏骤停后成功复苏且无 STEMI 迹象的患者中，与延迟造影策略相比，立即造影策略并未改善 90 天的总体存活率。（由荷兰心脏研究所等资助；COACT 荷兰试验注册编号，NTR4973。）
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