德国莱比锡大学Steffen Desch团队研究了无ST段抬高的院外心脏骤停后复苏患者进行血管造影时机对预后的影响。该研究于2021年8月29日发表于《新英格兰医学杂志》上。

心肌梗死是院外心脏骤停的常见原因。然而，对于心电图无ST段抬高证据的复苏患者，早期冠状动脉造影和血运重建的益处尚不清楚。

在这项多中心试验中，研究组招募了554例院外心脏骤停成功复苏、可能源于冠状动脉的患者，并将其随机分组，分别接受即时冠状动脉造影（即时冠状动脉造影组）或经初步重症监护评估后接受延迟或选择性血管造影（延迟血管造影组）。所有患者复苏后心电图均无ST段抬高迹象。主要终点是30天内的全因死亡。次要终点包括30天内的全因死亡或严重神经功能障碍的综合结局。

554例患者中有530例（95.7%）被纳入初步分析。在第30天，即时血管造影组265例患者中有143例（54.0%）死亡，延迟血管造影组265例患者中有122例（46.0%），风险比为1.28。直接血管造影组255例患者中有164例（64.3%）发生全因死亡或严重神经功能障碍的综合结局，延迟血管造影组248例患者中有138例（55.6%），风险比为1.16。两组患者的肌钙蛋白释放峰值以及中、重度出血、中风和肾脏替代治疗的发生率相似。

研究结果表明，对于院外心脏骤停复苏且无ST段抬高的患者，就30天内全因死亡风险而言，立即进行血管造影与延迟或选择性血管造影相比没有任何临床益处。

附：英文原文

Title: Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation | NEJM

Author: Steffen Desch, M.D.,, Anne Freund, M.D.,, Ibrahim Akin, M.D.,, Michael Behnes, M.D.,, Michael R. Preusch, M.D.,, Thomas A. Zelniker, M.D.,, Carsten Skurk, M.D.,, Ulf Landmesser, M.D.,, Tobias Graf, M.D.,, Ingo Eitel, M.D.,, Georg Fuernau, M.D.,, Hendrik Haake, M.D.,, Peter Nordbeck, M.D.,, Fabian Hammer, M.D., Ph.D.,, Stephan B. Felix, M.D.,, Christian Hassager, M.D.,, Thomas Engstrm, M.D.,, Stephan Fichtlscherer, M.D.,, Jakob Ledwoch, M.D.,, Karsten Lenk, M.D.,, Michael Joner, M.D.,, Stephan Steiner, M.D.,, Christoph Liebetrau, M.D.,, Ingo Voigt, M.D.,, Uwe Zeymer, M.D.,, Michael Brand, M.D.,, Roland Schmitz, M.D.,, Jan Horstkotte, M.D.,, Claudius Jacobshagen, M.D.,, Janine Pss, M.D.,, Mohamed Abdel-Wahab, M.D.,, Philipp Lurz, M.D., Ph.D.,, Alexander Jobs, M.D.,, Suzanne de Waha-Thiele, M.D.,, Denise Olbrich, Ph.D.,, Frank Sandig,, Inke R. Knig, Ph.D.,, Sabine Brett,, Maren Vens, Ph.D.,, Kathrin Klinge, Ph.D.,, and Holger Thiele, M.D.

Issue&Volume: 2021-08-29

Abstract: Background

Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear.

Methods

In this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days.

Results

A total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P=0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups.

Conclusions

Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause.

DOI: 10.1056/NEJMoa2101909

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2101909