22
Coronary angiography delayed until after neurological recovery
Immediate coronary angiography
Open-label; conducted in the Netherlands; the delayed arm still received angiography, so this is a trial of timing and not of angiography itself.
Adults successfully resuscitated after out-of-hospital cardiac arrest WITHOUT signs of ST-segment elevation myocardial infarction
Survival at 90 days
176 of 273 (64.5%) alive in the immediate group versus 178 of 265 (67.2%) in the delayed group; OR 0.89 (0.62 to 1.27), P = 0.51. No significant difference in any secondary endpoint. Median time to target temperature was LONGER with immediate angiography, 5.4 versus 4.7 hours, ratio of geometric means 1.19 (1.04 to 1.36).
Anything about ECPR. Every participant had a circulation, which is the one feature that changes the argument: in ECPR the pump has already restored coronary perfusion, so the case for angiography is diagnostic rather than a reperfusion-time case. COACT also excluded ST elevation, whereas the only mortality signal in the ECPR angiography literature is in ST-elevation patients from whom angiography was withheld.
In a resuscitated patient without ST elevation, immediacy of angiography buys nothing — and it costs time to temperature control. Chapter 22 uses the second half of that finding: the trip to the catheterisation laboratory has an opportunity cost measured in the other things that then do not happen on time.