Physician Update: AHA Special Edition
Read more articles from our most relevant research presented at the 2024 AHA Scientific Sessions.
Clinical Heart and Vascular Center
Resuscitation Science Symposium: Coronary Angiography and PCI – State of the Science in 2024
By Anezi Uzendu, M.D., FACC
Assistant Professor of Internal Medicine
Rescue coronary angiography and revascularization is often considered in patients with return of spontaneous circulation after cardiac arrest. Decades of observational data demonstrated high incidence of coronary artery disease – particularly among patients with shockable rhythm and ST elevation – and increased survival with early coronary angiography. However, over the past five years, seminal randomized controlled trials have been published that have changed our understanding of the field and altered international guidelines. At #AHA24, I summarized the state of coronary angiography and PCI after cardiac arrest in light of current evidence.
COACT, a 2019 multicenter trial from the Netherlands, randomized 552 patients with shockable, out-of-hospital cardiac arrest and no ST elevation on post-arrest ECG to immediate vs. delayed angiography. TOMAHAWK from 2021 was a multicenter international trial that enrolled 558 patients with both shockable and non-shockable rhythm and no ST elevation to immediate vs. delayed coronary angiography. Both trials were negative for survival or favorable neurologic outcome. Three more negative trials were published in this area of study (PEARL, COUPE, and EMERGE), but they were underpowered, not reaching their intended sample sizes.
“[O]ur recent 2023 AHA guideline update included a new Class III recommendation of no benefit for early or emergent coronary angiography in patients without ST elevation, clinical shock, or electrical instability.”
It is important to note that none of the trials included ST elevation, and COACT and TOMAHAWK excluded patients with clinical shock. All trials also allowed for crossover to emergent angiography if hemodynamic or electric instability developed. Thus, our recent 2023 AHA guideline update included a new Class III recommendation of no benefit for early or emergent coronary angiography in patients without ST elevation, clinical shock, or electrical instability. There remains a Class I recommendation for patients with STEMI after ROSC and a Class IIA recommendation for those with clinical shock or electrical instability.
