We start this lovely Wednesday with EMS bringing in a 70-year-old man who just had a v-fib/v-tach arrest. After 5 rounds of CPR, 4 shocks, and 3 doses of epi, they’ve got him back! You prep airway equipment and the ultrasound, and in a few minutes, the patient arrives.
Initial vitals: 130/70, HR 110, RR 20, O2 99%
His history is a bit unclear, but family mentions possible CAD. As nursing places a line, you grab an ECG and are surprised to see that it’s not very impressive! Given his recent v-fib/v-tach arrest, despite the benign ECG, you wonder if he should go straight to the cath lab anyhow. Early angio after a v-tach arrest should be life saving, right? It must be a clotted coronary, right? Well, let’s talk about it on this week's cheesy summary.
Background
The leading cause of adult cardiac arrest is ischemic heart disease, making immediate angiography after ROSC a reasonable consideration. Patients with shockable rhythm and STE post-ROSC have a prevalence of >85% for OMI. Those with a shockable rhythm but no STE show a much lower prevalence of coronary occlusion, from 5 - 30%. In patients without a shockable rhythm and no STE, OMI prevalence drops to an estimated 7%4.
In pediatrics, respiratory causes dominate, and they most frequently present in PEA or asystole. When cardiac causes are involved, they’re usually from congenital lesions, arrhythmias, or cardiomyopathies rather than CAD8.
Previously, based on observational studies, a call to cards for this patient likely would have prompted a trip to the cath lab, but a few large RCTs have addressed this exact question and called to question this .
COACT Trial 2019
The first study, COACT, randomized 552 patients with out-of-hospital cardiac arrest (OHCA) and a shockable rhythm without signs of STE on post-ROSC ECG. Those with nonshockable rhythms or STEMI were excluded. Immediate angiography (within 2 hours of randomization) vs delayed angiography (angio after neurologic recovery) showed no difference in 90-day survival1. Additional sub-studies of the COACT trial revealed no changes in one-year survival rates, quality of life, heart failure admissions, or change in baseline LV function between groups2-4.
TOMAHAWK Trial 2021
The TOMAHAWK trial looked at this same question but included patients with both shockable and non-shockable rhythms in OHCA. Of the 530 randomized patients, a culprit coronary lesion was identified in 40% of participants. Death at 30 days did not significantly differ between early vs delayed angiography (p=0.06), however, the composite of death or severe neurologic deficit was surprisingly higher in the immediate angio group5. The reason for this higher risk of harm in the immediate angio group is unclear - perhaps the focus on cath diverted attention from other reversible causes earlier.
EMERGE Trial 2022
The most recent trial is EMERGE, evaluating 279 patients with OHCA with any rhythm type and without STE on post-ROSC ECG. Though underpowered due to early termination, when comparing immediate and delayed angio, it also found no significant difference in 180-day outcomes6.
ECG Considerations
One consideration not incorporated into these trials is high-risk ECG features. Features including de Winter Sign, Wellens sign, hyperacute T waves, contiguous ST depression, or single-lead STE improves OMI identification in OHCA patients9. Conversely, transient STE post-ROSC can be misleading. Ischemia during CPR, prolonged downtime, and global hypoperfusion can all cause falsely positive STE despite no present OMI. One study of 586 patients found an 18.5% false-positive rate if the ECG was obtained <8 minutes post-ROSC - so consider repeating your ECG to confirm persistent STE changes7.
Conclusion
Your patient goes back into V-fib, you shock him back to life, and he’s admitted to the CCU neurologically intact. He’s cathed the following day and discharged with a life vest.
For post-ROSC patients without STE, take in the whole picture - neurologic status, hemodynamic stability, other possible causes of arrest, and medical history, before pushing cards for immediate cath. Early angio isn’t always the answer.
Stay cheesy team! 🧀
Citations
Lemkes J.S., Janssens G.N., van der Hoeven N.W., et al. Coronary angiography after cardiac arrest without ST-segment elevation. N Engl J Med. 2019;380(15):1397–1407. doi: 10.1056/NEJMoa1816897.
Degrell, P., Varenne, O., Waldmann, V., Bonnet, G., Spaulding, C., Kim, Y.-J., Kim, W. Y., De Silva, K., Perera, D., Lemkes, J. S., Janssens, G. N., & van Royen, N. (2019). Coronary Angiography after Cardiac Arrest without ST-Segment Elevation. The New England Journal of Medicine, 381(2), 188–190. https://doi.org/10.1056/NEJMc1906523
Lemkes, J. S., Janssens, G. N., van der Hoeven, N. W., Jewbali, L. S. D., Dubois, E. A., Meuwissen, M. M., Rijpstra, T. A., Bosker, H. A., Blans, M. J., Bleeker, G. B., Baak, R. R., Vlachojannis, G. J., Eikemans, B. J. W., van der Harst, P., van der Horst, I. C. C., Voskuil, M., van der Heijden, J. J., Beishuizen, A., Stoel, M., … van Royen, N. (2020). Coronary Angiography after Cardiac Arrest without ST Segment Elevation: One-Year Outcomes of the COACT Randomized Clinical Trial. https://doi.org/10.1001/jamacardio.2020.3670
Kumar S, Abdelghaffar B, Iyer M, Shamaileh G, Nair R, Zheng W, Verma B, Menon V, Kapadia SR, Reed GW. Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation on Electrocardiograms: A Comprehensive Review. J Soc Cardiovasc Angiogr Interv. 2022 Nov 25;2(1):100536. doi: 10.1016/j.jscai.2022.100536. PMID: 39132520; PMCID: PMC11307500.
Desch S., Freund A., Akin I., et al. Angiography after out-of-hospital cardiac arrest without ST-segment elevation. N Engl J Med. 2021;385(27):2544–2553. doi: 10.1056/NEJMoa2101909
Hauw-Berlemont, C., Lamhaut, L., Diehl, J.-L., Andreotti, C., Varenne, O., Leroux, P., Lascarrou, J.-B., Guerin, P., Loeb, T., Roupie, E., Daubin, C., Beygui, F., Boissier, F., Marjanovic, N., Christiaens, L., Vilfaillot, A., Glippa, S., Prat, J. D., Chatellier, G., … Spaulding, C. (2022). Emergency vs Delayed Coronary Angiogram in Survivors of Out-of-Hospital Cardiac Arrest: Results of the Randomized, Multicentric EMERGE Trial. JAMA Cardiology, 7(7), 700–707. https://doi.org/10.1001/jamacardio.2022.1416
.Baldi E., Schnaubelt S., Caputo M.L., et al. Association of timing of electrocardiogram acquisition after return of spontaneous circulation with coronary angiography findings in patients with out-of-hospital cardiac arrest. JAMA Netw Open. 2021;4(1) doi: 10.1001/jamanetworkopen.2020.32875.
Lovik K, Sasaki J, Edemekong PF. Cardiopulmonary Arrest in Children. [Updated 2025 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436018/
Silwanis C. (2025). Beyond STEMI: High-risk ECG patterns as predictors of occlusive myocardial infarction in out-of-hospital cardiac arrest patients. Resuscitation., 215.I
Authored by Samson Frendo MD and Eric Leser MD