• Michelle Welsford, Matthias Bossard, Colleen Shortt, Jodie Pritchard, Madhu K Natarajan, and Emilie P Belley-Côté.
• Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada; Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Ontario, Canada. Electronic address: dr.m@welsford.ca.
• Can J Cardiol. 2018 Feb 1; 34 (2): 180-194.

BackgroundIn patients with out-of-hospital cardiac arrest who achieve return of spontaneous circulation, coronary angiography (CAG) might improve outcomes. We conducted a systematic review and meta-analysis to elucidate the benefit and optimal timing of early CAG in comatose out-of-hospital cardiac arrest patients with return of spontaneous circulation.MethodsWe searched MEDLINE, EMBASE, and Cochrane from 1990 to May 2017. Studies reporting survival and/or neurological survival in early (< 24-hour) vs late/no CAG were selected. We used the Clinical Advances Through Research and Information Translation (CLARITY) risk of bias in cohort studies tool and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria to assess risk of bias and quality of evidence, respectively. Results were pooled using random effects and presented as risk ratios (RRs) with 95% confidence intervals (CIs).ResultsAfter screening 9185 titles/abstracts and 631 full-text articles, we included 23 nonrandomized studies. Short (to discharge or 30 days) and long-term (1-5 years) survival were significantly improved (52% and 56%, respectively) in the early < 24-hour CAG group compared with the late/no CAG group (RR, 1.52; 95% CI, 1.32-1.74; P < 0.00001; I2, 94% and RR, 1.56; 95% CI, 1.14-2.14; P = 0.006; I2, 86%). Survival with good neurological outcome was also improved by 69% in the < 24-hour CAG group at short- (RR, 1.69; 95% CI, 1.40-2.04; P < 0.00001; I2, 93%) and intermediate-term (3-11 months; RR, 1.49; 95% CI, 1.27-1.76; P < 0.00001; I2, 67%). We found consistent benefits in the < 2-hour and < 6-hour subgroups. Early CAG was associated with significantly better outcomes in studies of patients without ST-elevation, but the results did not reach statistical significance in studies of patients with ST-elevation.ConclusionsOn the basis of very low quality, but consistent evidence, early CAG (< 24 hours) was associated with significantly higher survival and better neurologic outcomes.Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

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