Intensive Care Medicine

, Volume 41, Issue 5, pp 856–864 | Cite as

Survival in patients without acute ST elevation after cardiac arrest and association with early coronary angiography: a post hoc analysis from the TTM trial

  • J. Dankiewicz
  • N. Nielsen
  • M. Annborn
  • T. Cronberg
  • D. Erlinge
  • Y. Gasche
  • C. Hassager
  • J. Kjaergaard
  • T. Pellis
  • H. Friberg



To investigate whether early coronary angiography (CAG) after out-of-hospital cardiac arrest of a presumed cardiac cause is associated with improved outcomes in patients without acute ST elevation.


The target temperature management after out-of-hospital cardiac arrest (TTM) trial showed no difference in all-cause mortality or neurological outcome between an intervention of 33 and 36 °C. In this post hoc analysis, 544 patients where the admission electrocardiogram did not show acute ST elevation were included. Early CAG was defined as being performed on admission or within the first 6 h after arrest. Primary outcome was mortality at the end of trial. A Cox proportional hazard model was created to estimate hazard of death, adjusting for covariates. In addition, a propensity score matched analysis was performed.


A total of 252 patients (46 %) received early CAG, whereas 292 (54 %) did not. At the end of the trial, 122 of 252 patients who received an early CAG (48 %) and 159 of 292 patients who did not (54 %) had died. The adjusted hazard ratio for death was 1.03 in the group that received an early CAG; 95 % CI 0.80–1.32, p = 0.82. In the propensity score analysis early CAG was not significantly associated with survival.


In this post hoc observational study of a large randomized trial, early coronary angiography for patients without acute ST elevation after out-of-hospital cardiac arrest of a presumed cardiac cause was not associated with improved survival. A randomized trial is warranted to guide clinical practice.


Cardiac arrest Coronary angiography Coronary intervention Hypothermia Outcome Survival 



Support was provided by independent research grants from the Swedish Heart–Lung Foundation, Arbetsmarknadens Försäkringsaktiebolag Insurance foundation, Swedish Research Council, Region Skåne (Sweden), National Health Service (Sweden), Thelma Zoegas Foundation, Krapperup Foundation, Thure Carlsson Foundation, Hans-Gabriel and Alice Trolle-Wachtmeister Foundation for Medical Research, Skåne University Hospital, TrygFonden (Denmark), European Clinical Research Infrastructures Network, European Union Interreg programme IV A.

Conflicts of interest

Hans Friberg, Niklas Nielsen, and Tommaso Pellis have received lecture fees from Bard Medical.

Supplementary material

134_2015_3735_MOESM1_ESM.docx (206 kb)
Supplementary material 1 (DOCX 205 kb)


  1. 1.
    Zheng Z, Croft J, Giles W, Mensah G (2001) Sudden cardiac death in the United States, 1989–1998. Circulation 104:2158–2163CrossRefPubMedGoogle Scholar
  2. 2.
    Spaulding C, Joly L, Rosenberg A, Monchi M, Weber S, Dhainaut J et al (1997) Immediate coronary angiography in survivors of out-of-hospital cardiac arrest. N Engl J Med 336:1629–1633CrossRefPubMedGoogle Scholar
  3. 3.
    Bro-Jeppesen J, Kjaergaard J, Wanscher M, Pedersen F, Holmvang L, Lippert F et al (2012) Emergency coronary angiography in comatose cardiac arrest patients: do real-life experiences support the guidelines? Eur Heart J Acute Cardiovasc Care 1:291–301CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J et al (2010) Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian region out of hospital cardiac arrest) registry. Circ Cardiovasc Interv 3:200–207CrossRefPubMedGoogle Scholar
  5. 5.
    Hollenbeck R, McPherson J, Mooney M, Unger B, Patel N, McMullan P et al (2014) Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation 85:88–95CrossRefPubMedGoogle Scholar
  6. 6.
    Sunde K, Pytte M, Jacobsen D, Mangschau A, Jensen L, Smedsrud C et al (2007) Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest. Resuscitation 73:29–39CrossRefPubMedGoogle Scholar
  7. 7.
    O’Connor R, Brady W, Brooks S, Diercks D, Egan J, Ghaemmaghami C et al (2010) Part 10: acute coronary syndromes: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122:817Google Scholar
  8. 8.
    Sideris G, Voicu S, Dillinger JG, Stratiev V, Logeart D, Broche C et al (2011) Value of post-resuscitation electrocardiogram in the diagnosis of acute myocardial infarction in out-of-hospital cardiac arrest patients. Resuscitation 82:1148–1153CrossRefPubMedGoogle Scholar
  9. 9.
    Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard J-MM et al (2009) Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am Heart J 157:312–318CrossRefPubMedGoogle Scholar
  10. 10.
    Radsel P, Knafelj R, Kocjancic S, Noc M (2011) Angiographic characteristics of coronary disease and postresuscitation electrocardiograms in patients with aborted cardiac arrest outside a hospital. Am J Cardiol 108:634–638CrossRefPubMedGoogle Scholar
  11. 11.
    Dumas F, Manzo-Silberman S, Fichet J, Mami Z, Zuber B, Vivien B et al (2012) Can early cardiac troponin I measurement help to predict recent coronary occlusion in out-of-hospital cardiac arrest survivors? Crit Care Med 40:1777–1784CrossRefPubMedGoogle Scholar
  12. 12.
    Niklas N, Jørn W, Tobias C, David E, Yvan G, Christian H et al (2013) Targeted temperature management at 33 vs. 36 °C after cardiac arrest. N Engl J Med 369(23):2197–2206CrossRefGoogle Scholar
  13. 13.
    Nielsen N, Wetterslev J, Al-Subaie N, Andersson B, Bro-Jeppesen J, Bishop G (2012) Target temperature management after out-of-hospital cardiac arrest—a randomized, parallel-group, assessor-blinded clinical trial—rationale and design. Am Heart J 163:541–548CrossRefPubMedGoogle Scholar
  14. 14.
    Langhelle A, Nolan J, Herlitz J, Castren M, Wenzel V, Soreide E et al (2005) Recommended guidelines for reviewing, reporting, and conducting research on post-resuscitation care: the Utstein style. Resuscitation 66:271–283CrossRefPubMedGoogle Scholar
  15. 15.
    Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD et al (2012) Third universal definition of myocardial infarction. J Am Coll Cardiol 60:1581–1598CrossRefPubMedGoogle Scholar
  16. 16.
    Jain S, Ting HT, Bell M, Bjerke CM, Lennon RJ, Gersh BJ et al (2011) Utility of left bundle branch block as a diagnostic criterion for acute myocardial infarction. Am J Cardiol 107:1111–1116CrossRefPubMedGoogle Scholar
  17. 17.
    Neeland IJ, Kontos MC, de Lemos JA (2012) Evolving considerations in the management of patients with left bundle branch block and suspected myocardial infarction. J Am Coll Cardiol 60:96–105CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, O’Gara PT, Kushner FG, Ascheim DD (2013) 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2013(61):e78–e140Google Scholar
  19. 19.
    Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1:480–484CrossRefPubMedGoogle Scholar
  20. 20.
    Leuven E, Siansei B (2003) PSMATCH2: Stata module to perform full Mahalanobis and propensity score matching, common support graphing, and covariate imbalance testing. Available via
  21. 21.
    Abadie A, Imbens GW (2012) Matching on the estimated propensity score. Harvard University and National Bureau of Economic Research. Available via
  22. 22.
    Austin PC (2014) The use of propensity score methods with survival or time-to-event outcomes: reporting measures of effect similar to those used in randomized experiments. Stat Med 33:1242–1258CrossRefPubMedCentralPubMedGoogle Scholar
  23. 23.
    Strote J, Maynard C, Olsufka M, Nichol G, Copass M, Cobb L et al (2012) Comparison of role of early (less than 6 h) to later (more than 6 h) or no cardiac catheterization after resuscitation from out-of-hospital cardiac arrest. Am J Cardiol 109:451–454CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K et al (2009) Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest. Acta Anaesthesiol Scand 53:926–934CrossRefPubMedGoogle Scholar
  25. 25.
    Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD et al (1999) Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. N Engl J Med 341:625–634CrossRefPubMedGoogle Scholar
  26. 26.
    Annborn M, Bro-Jeppesen J, Nielsen N, Ullén S, Kjaergaard J, Hassager C et al (2014) The association of targeted temperature management at 33 and 36 °C with outcome in patients with moderate shock on admission after out-of-hospital cardiac arrest: a post hoc analysis of the target temperature management trial. Intensive Care Med 40:1210–1219CrossRefPubMedGoogle Scholar
  27. 27.
    Navarese EP, Gurbel PA, Andreotti F, Tantry U, Jeong Y-HH, Kozinski M et al (2013) Optimal timing of coronary invasive strategy in non-ST-segment elevation acute coronary syndromes: a systematic review and meta-analysis. Ann Intern Med 158:261–270CrossRefPubMedGoogle Scholar
  28. 28.
    Dragancea I, Rundgren M, Englund E, Friberg H, Cronberg T (2013) The influence of induced hypothermia and delayed prognostication on the mode of death after cardiac arrest. Resuscitation 84:337–342CrossRefPubMedGoogle Scholar
  29. 29.
    Brieger D, Fox KA, Fitzgerald G, Eagle KA, Avezum A, Steg PG (2009) Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the global registry of acute coronary events. Heart 95:888–894CrossRefPubMedGoogle Scholar
  30. 30.
    Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J et al (2014) 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014(35):2541–2619Google Scholar
  31. 31.
    Noc M, Fajadet J, Lassen JF, Kala P, MacCarthy P, Olivecrona GK et al (2014) Invasive coronary treatment strategies for out-of-hospital cardiac arrest: a consensus statement from the European Association for Percutaneous Cardiovascular Interventions (EAPCI)/Stent for Life (SFL) groups. EuroIntervention 10:31–37CrossRefPubMedGoogle Scholar
  32. 32.
    Erlinge D, Götberg M, Lang I, Holzer M, Noc M, Clemmensen P et al (2014) Rapid endovascular catheter core cooling combined with cold saline as an adjunct to percutaneous coronary intervention for the treatment of acute myocardial infarction (the CHILL-MI trial). J Am Coll Cardiol 63(18):1857–1865CrossRefPubMedGoogle Scholar
  33. 33.
    Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG et al (2010) Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol 55:2435–2445CrossRefPubMedGoogle Scholar
  34. 34.
    Tømte O, Andersen GØ, Jacobsen D, Drægni T, Auestad B, Sunde K (2011) Strong and weak aspects of an established post-resuscitation treatment protocol—a five-year observational study. Resuscitation 82:1186–1193CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2015

Authors and Affiliations

  • J. Dankiewicz
    • 1
    • 2
  • N. Nielsen
    • 2
  • M. Annborn
    • 1
    • 2
  • T. Cronberg
    • 2
    • 3
  • D. Erlinge
    • 2
    • 4
  • Y. Gasche
    • 5
  • C. Hassager
    • 6
  • J. Kjaergaard
    • 6
  • T. Pellis
    • 7
  • H. Friberg
    • 1
    • 2
  1. 1.Department of Intensive and Perioperative CareSkåne University HospitalLundSweden
  2. 2.Department of Clinical SciencesLund UniversityLundSweden
  3. 3.Department of NeurologySkåne University HospitalLundSweden
  4. 4.Department of CardiologySkåne University HospitalLundSweden
  5. 5.Department of Intensive CareGeneva University HospitalGenevaSwitzerland
  6. 6.Department of Cardiology, The Heart CentreCopenhagen University Hospital (Rigshospitalet)CopenhagenDenmark
  7. 7.Emergency Medical Service, Anaesthesia and Intensive CareSanta Maria degli Angeli HospitalPordenoneDenmark

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