Spoormans Eva Marie, Thevathasan Tharusan, van Royen Niels, Zwinderman Aeilko H, Freund Anne, Thiele Holger, Ziesemer Kirsten, Desch Steffen, Lemkes Jorrit S
Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands.
German Centre for Cardiovascular Research (DZHK), Berlin, Germany.
JAMA Cardiol. 2025 May 28. doi: 10.1001/jamacardio.2025.1194.
Several randomized clinical trials (RCTs) assessed the effect of immediate vs delayed coronary angiography in patients with out-of-hospital cardiac arrest (OHCA) without ST-segment elevations and found no difference in short-term survival. However, the association of these strategies with long-term outcomes and the identification of patient subgroups that might benefit from tailored approaches remain unclear.
To compare immediate vs delayed or selective coronary angiography treatment strategies for patients with OHCA without ST elevation and the effect on 1-year survival, and identify subgroups that may differ in treatment effect based on patient or clinical features.
Ovid MEDLINE, Embase, and Clarivate/Web of Science Core Collection were searched for relevant literature from inception to September 8, 2022.
RCTs investigating immediate vs delayed or selective coronary angiography after OHCA without ST-segment elevations and a minimum follow-up period of 1 year. Data were combined using the 1-stage individual participant data meta-analysis (IPDMA) approach.
Individual patient data were obtained from RCTs that met the eligibility criteria: COACT (Coronary Angiography After Cardiac Arrest) and TOMAHAWK (Immediate Unselected Coronary Angiography vs Delayed Triage in Survivors of Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation).
The primary end point was 1-year survival. Secondary outcomes included the identification of variations in treatment effect using subgroup analysis (based on age, sex, arrest rhythm, witnessed arrest, time to basic life support, time to return of spontaneous circulation, and history of coronary artery disease, diabetes, and hypertension) and clinical outcomes (eg, myocardial infarction and heart failure) at 1 year.
For the IPDMA, data were derived from 2 RCTs comprising a total of 1031 patients. In the immediate angiography group, 259 of 522 (49.6%) survived until 1 year vs 272 of 509 (53.4%) in the delayed or selective angiography group (stratified by randomized trial; hazard ratio, 1.15 [95% CI, 0.96-1.37). No treatment-by-subgroup interactions were identified that suggested heterogeneity between the 2 groups (P values for interaction ranged from P = .26 to P = .91 across subgroups).
In this IPDMA of 2 RCTs, there was no benefit of immediate coronary angiography compared with a delayed or selective strategy during 1-year follow-up in successfully resuscitated patients with OHCA without ST-segment elevations. No subgroup of patients was identified that showed a differential treatment effect.
PROSPERO Identifier: CRD42022346559; COACT Netherlands Trial Register Identifier: NTR4973; TOMAHAWK ClinicalTrials.gov Identifier: NCT02750462.
多项随机临床试验（RCT）评估了院外心脏骤停（OHCA）且无ST段抬高患者立即进行冠状动脉造影与延迟进行冠状动脉造影的效果，发现短期生存率无差异。然而，这些策略与长期预后的关联以及可能从个性化方法中获益的患者亚组的识别仍不明确。
比较OHCA无ST段抬高患者立即进行冠状动脉造影与延迟或选择性冠状动脉造影的治疗策略及其对1年生存率的影响，并根据患者或临床特征识别治疗效果可能不同的亚组。
检索了Ovid MEDLINE、Embase和Clarivate/Web of Science核心合集，以获取从创刊至2022年9月8日的相关文献。
调查OHCA无ST段抬高后立即进行冠状动脉造影与延迟或选择性冠状动脉造影且最短随访期为1年的RCT。使用1阶段个体参与者数据荟萃分析（IPDMA）方法合并数据。
个体患者数据来自符合纳入标准的RCT：COACT（心脏骤停后冠状动脉造影）和TOMAHAWK（院外心脏骤停无ST段抬高幸存者立即非选择性冠状动脉造影与延迟分诊）。
主要终点为1年生存率。次要结局包括使用亚组分析（基于年龄、性别、骤停节律、目击骤停、开始基本生命支持的时间、自主循环恢复时间以及冠状动脉疾病、糖尿病和高血压病史）识别治疗效果的差异，以及1年时的临床结局（如心肌梗死和心力衰竭）。
对于IPDMA，数据来自2项RCT，共1031例患者。在立即冠状动脉造影组中，522例中有259例（49.6%）存活至1年，而在延迟或选择性冠状动脉造影组中，509例中有272例（53.4%）存活至1年（按随机试验分层；风险比，1.15[95%CI，0.96 - 1.37]）。未发现提示两组之间存在异质性的治疗亚组交互作用（各亚组的交互P值范围为P = 0.26至P = 0.91）。
在这项对2项RCT的IPDMA中，对于成功复苏的OHCA无ST段抬高患者，在1年随访期间，与延迟或选择性策略相比，立即冠状动脉造影无益处。未识别出显示出不同治疗效果的患者亚组。
PROSPERO标识符：CRD42022346559；COACT荷兰试验注册标识符：NTR4973；TOMAHAWK临床研究注册号：NCT02750462。
