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.

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.

Influence of hemoglobin level on in-hospital prognosis in patients with acute coronary syndrome.

INTRODUCTION AND OBJECTIVES: Many patients with acute coronary syndrome (ACS) suffer from anemia. The objective of this study was to determine the influence of the admission hemoglobin level and the post-admission fall in hemoglobin level on short-term prognosis during hospitalization. METHODS: This retrospective study involved 542 high-risk ACS patients who were admitted during 2005. The hemoglobin level was recorded on admission and at least every 24 hours thereafter, with anemia being defined according to WHO criteria. Logistic regression modeling was used to assess the relationship of the admission hemoglobin level and the fall in hemoglobin level to all-cause mortality and cardiogenic shock during hospitalization. RESULTS: During follow-up (median time, 7 days), the incidence of cardiogenic shock or mortality was 6.9% (37 patients). Anemia was present in 147 patients (27.1%) at admission, increasing to 266 patients (49.1%) during hospitalization (P< .0001). After adjusting for a range of variables, independent associations were found between the occurrence of adverse events and both the admission hemoglobin level (odds ratio [OR]=1.4 for each 1 g/dL below normal; 95% confidence interval [CI], 1.1-1.8; P=.003) and a fall in hemoglobin level >1.8 g/dL (OR=5.4; 95% CI, 1.5-18.8; P=.009). CONCLUSIONS: In high-risk ACS patients both the admission hemoglobin level and a subsequent fall in hemoglobin level >1.8 g/dL were associated with an increased risk of all-cause mortality or cardiogenic shock.