Coronary Angiography After Cardiac Arrest

Despite 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. 1,2However, 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. 3It 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