Immediate coronary angiography does not improve survival after out-of-hospital cardiac arrest without ST elevation

Immediate coronary angiography did not improve 30-day survival compared with a deferred strategy in patients without an ECG ST-elevation after out-of-hospital cardiac arrest (搜索)搜索该疾病 (OHCA), according to the DISCO trial and an accompanying meta-analysis presented in a Hot Line session at ESC Congress 2026.

"Immediate coronary angiography of the cardiac arrest does not improve survival or neurological outcomes. The case is closed," said Sten Rubertsson, MD, PhD, professor of anesthesiology and intensive care medicine at Uppsala University in Sweden, during a press conference at the European Society of Cardiology Congress.

Clinical dilemma and study rationale

Acute coronary syndrome (搜索)搜索该疾病 is a common cause of OHCA. In patients presenting with an ST-elevation on an ECG, immediate coronary angiography to assess artery blockages is recommended, with subsequent percutaneous coronary intervention (PCI) where necessary to restore blood flow. However, evidence for the use of coronary angiography in patients without an ECG ST-elevation has been limited.

Current guidelines recommend a deferred rather than an immediate strategy for coronary angiography, based mainly on the neutral results from two medium-sized trials. Yet clinical practice varies widely, potentially due to the lack of definitive evidence on hard clinical outcomes. The DISCO trial aimed to determine whether immediate coronary angiography improves survival in patients after an OHCA without an ST-elevation.

Trial design and patient population

The trial was conducted in 23 centers in Sweden, Denmark and the Netherlands. Adult unconscious patients with witnessed OHCA, return of spontaneous circulation and without ST-elevation on prehospital or emergency department ECG were included. Patients were randomized 1:1 to immediate coronary angiography (within 120 minutes) or to a deferred strategy in which coronary angiography was intended to be delayed for at least 72 hours. In cases of electrical or haemodynamic instability, coronary angiography could be performed before 72 hours.

In the immediate group, PCI was recommended on the presumed culprit lesion, while non-culprit lesions were not to be treated during the acute procedure. A total of 1,006 patients were included, with a mean age of 67 years and around one-quarter being women.

Primary and secondary outcomes

No difference in the primary endpoint of survival at 30 days was observed between immediate and deferred coronary angiography (54.6% vs. 53.6%; hazard ratio [HR] 0.95; 95% confidence interval [CI] 0.74 to 1.21; p=0.67). Similarly, there was no difference between the groups for survival at 180 days (deferred group, 50.2%; immediate group, 48.8%; p=0.6).

There were also no significant differences in secondary endpoints related to neurological recovery. The Modified Rankin Scale score of 0 to 3 at 30 days was 43.6% in the deferred group versus 39.5% in the immediate group (p=0.19), and at 180 days was 41.6% versus 38.9% (p=0.37). The Cerebral Performance Category score of 1 to 2 at 30 days was 44.2% versus 39.1% (p=0.1), and at 180 days was 42% versus 39.1% (p=0.34).

"With these results from the largest randomized trial investigating this clinical dilemma, we can now conclusively say that immediate coronary angiography after OHCA does not improve outcomes over a deferred strategy," stated Professor Rubertsson.

Meta-analysis confirms findings

Researchers from Radboud University Medical Center, Nijmegen, the Netherlands, led by Professor Niels van Royen, conducted an individual patient data meta-analysis of five randomized controlled trials, which included DISCO and involved data from 2,173 patients. As presented by Ms Lente Pol, there was no difference in 30-day survival between patients who received immediate coronary angiography and those who did not.

"These results show that we can safely delay coronary angiography in patients after OHCA without ST elevation," she concluded.

Clinical implications

"The DISCO study provides solid support for the current guideline recommendation against routine immediate coronary angiography in patients successfully resuscitated without ST elevation on ECG after out-of-hospital cardiac arrest (搜索)搜索该疾病," Rubertsson said. "These results may impact the acute care of resuscitated out-of-hospital cardiac arrests in a crude estimate of about 35,000 to 40,000 people per year in Europe ... if they follow the guidelines. So I think we can say that this question is closed and further studies on how to improve survival in cardiac arrest are warranted."

The DISCO study was the largest to examine whether immediate coronary angiography was better than deferred coronary angiography in this patient population, confirming the results of four previous smaller studies and supporting ESC guideline recommendations against immediate coronary angiography.

Looking ahead, Rubertsson expressed that the most hope may lie in preventing cardiac arrests from occurring in the first place, and called for a renewed focus on pre-hospital care. "I am a little bit discouraged by all the larger studies that we have performed lately trying to find a magic bullet in post-resuscitation care," he said. "I think it's very difficult to find something that will really change the outcome. I think what we need to do is go back to the ... pre-hospital care arena because that's where we have the chance to do something that might change the outcome in the end."