Role of coronary angiography in patients with a non-diagnostic electrocardiogram following out of hospital cardiac arrest: Rationale and design of the multicentre randomized controlled COUPE trial

Abstract

Background: Coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA). The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following cardiac arrest in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear. Aims: We aim to assess whether emergency CAG and PCI, when indicated, will improve survival with good neurological outcome in post-OHCA patients without STEMI who remain comatose. Methods: COUPE is a prospective, multicentre and randomized controlled clinical trial. A total of 166 survivors of OHCA without STEMI will be included. Potentially non-cardiac aetiology of the cardiac arrest will be ruled out prior to randomization. Randomization will be 1:1 for emergency (within 2 h) or deferred (performed before discharge) CAG. Both groups will receive routine care in the intensive cardiac care unit, including therapeutic hypothermia. The primary efficacy endpoint is a composite of in-hospital survival free of severe dependence, which will be evaluated using the Cerebral Performance Category Scale. The safety endpoint will be a composite of major adverse cardiac events including death, reinfarction, bleeding and ventricular arrhythmias. Conclusions: This study will assess the efficacy of an emergency CAG versus a deferred one in OHCA patients without STEMI in terms of survival and neurological impairment.

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation

“…The clinically most meaningful difference between both trials is that the COACT study enrolled only patients with OHCA with a shockable arrest rhythm, whereas the TOMAHAWK trial recruited patients with both shockable and nonshockable rhythms and thus a broader risk spectrum. In addition to the 2 large trials (TOMAHAWK and COACT), 4 small randomized trials comparing immediate and delayed or selective coronary angiography in OHCA have been published . At short-term follow-up, there was also no benefit of emergency angiography.…”

Early coronary angiography in patients after out‐of‐hospital cardiac arrest without ST‐segment elevation: Meta‐analysis of randomized controlled trials

“…Several ongoing RCTs address the question of the present analysis, including trials either in both comatose and non‐comatose OHCA survivors (DISCO 16 and COUPE 17 ) or solely in non‐comatose patients (DISCO‐noCOMA 18 ). However, the results of the published RCTs are consistent and the present meta‐analysis does not support a recommendation of early coronary angiography in patients with OHCA without ST‐segment elevation.…”

Percutaneous Coronary Revascularization after Out-of-Hospital Cardiac Arrest: A Review of the Literature and a Case Series

“…Several randomized clinical trials are still ongoing [ 29 , 30 , 31 , 32 , 33 ]. Results from pilot studies from the DISCO (Direct or subacute coronary angiography in out-of-hospital cardiac arrest), ARREST trial (A randomized trial of expedited transfer to a cardiac arrest center for non-STE ventricular fibrillation OHCA) and from the prematurely terminated PEARL trial (Early coronary angiography versus delayed coronary angiography) are already available and confirmed no significant difference in mortality between early and delayed CAG in OHCA without STE ( Table 1 ).…”