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KEY CLINICAL QUESTION

Has DISCO closed the case against immediate angiography—or clarified why the ECG must remain one part of a wider post-arrest assessment?

THE EVIDENCE

WHAT IS DISCO?

DISCO—Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest—is a randomised clinical trial examining whether immediate coronary angiography improves outcomes after resuscitated OHCA when the post-ROSC ECG shows no ST elevation.

The full trial randomised 1,006 unconscious adults following witnessed OHCA with sustained ROSC and no ST elevation across 23 centres in Sweden, Denmark and the Netherlands. It compared angiography intended within 120 minutes with a strategy deferred for at least 72 hours.9

WHY WE STOPPED TO READ IT

The question did not begin with DISCO. COACT, TOMAHAWK and EMERGE had already failed to demonstrate improved survival from a routine immediate strategy in selected patients after OHCA without ST elevation.234

DISCO matters because it adds 1,006 randomised patients—the largest individual randomised dataset addressing this question to date. It is new evidence, not new UK ambulance guidance.

54.6%Immediate angiography
53.6%Deferred strategy

No statistically significant difference: HR 0.95 (95% CI 0.74–1.21); p=0.67. Survival at 180 days and neurological outcomes also did not differ significantly.9

INTERPRETATION

WHAT THIS DOES NOT MEAN

  1. 01It does not apply to every patient after ROSC. DISCO studied unconscious adults following witnessed OHCA, sustained ROSC and no ST elevation.
  2. 02No ST elevation does not mean no coronary pathology. Culprit lesions can be present despite absent ST elevation.1
  3. 03It does not mean unstable patients should wait. Earlier angiography was permitted if electrical or haemodynamic instability developed.
  4. 04A neutral result does not identify every subgroup. Trial eligibility, subgroup size and representation of unstable patients limit generalisation.56
OUR READDISCO makes the word “routine” more important than the words “cath lab”.

DISCO now sits alongside COACT, TOMAHAWK, EMERGE and pooled analyses pointing in the same direction: routine immediate angiography has not demonstrated a survival advantage across the selected OHCA-without-ST-elevation populations studied.

ON SHIFT

WHAT THIS MEANS IN PRACTICE

For UK prehospital clinicians, DISCO should not create a new binary destination rule. Current RCUK guidance should continue to govern practice. Assessment following ROSC extends beyond the presence or absence of ST elevation and includes the wider clinical context.78

Prehospital implication: rather than reducing the patient to “STEMI” or “not STEMI”, communicate the wider arrest story—arrest circumstances, initial rhythm, ROSC course, haemodynamic state, electrical instability and evolving ECG findings.

DISCO informs the probability discussion. It does not replace the pathway.

THE BOTTOM LINE

  1. 01Routine is the key word. No survival advantage has been demonstrated from routine immediate angiography in the selected RCT populations.
  2. 02No ST elevation is not no occlusion. The ECG is part of the assessment, not a coronary rule-out test.
  3. 03Know who was studied. External validity matters before applying a population result to a different patient.
  4. 04Instability changes the question. DISCO allowed earlier angiography for electrical or haemodynamic instability.
  5. 05Evidence informs. Guidance governs. DISCO does not independently change RCUK guidance or local pathways.

READ THE EVIDENCE

  1. Al Lawati, K., Forestell, B., Binbraik, Y., Sharif, S., Ainsworth, C., Mathew, R., Amin, F., Al Fawaz, M., Pinilla-Echeverri, N., Belley-Cote, E., Welsford, M. and Rochwerg, B. (2023). Early versus delayed coronary angiography after out-of-hospital cardiac arrest without ST-segment elevation—a systematic review and meta-analysis of randomized controlled trials. Critical Care Explorations.
  2. Hamidi, F., Anwari, E., Spaulding, C., Hauw-Berlemont, C., Vilfaillot, A., Viana-Tejedor, A., Kern, K., Hsu, C., Bergmark, B., Qamar, A., Bhatt, D., Furtado, R., Myhre, P., Hengstenberg, C., Lang, I., Frey, N., Freund, A., Desch, S., Thiele, H., Preusch, M. and Zelniker, T. (2024). Early versus delayed coronary angiography in patients with out-of-hospital cardiac arrest and no ST-segment elevation: A systematic review and meta-analysis of randomized controlled trials. Clinical Research in Cardiology.
  3. Deakin, C., Benson Clarke, A., Boulton, A., DeBono, J., Gosling, A., Greig, P., Pocock, H. and Wragg, V. (2025). Special circumstances guidelines.
  4. Nolan, J., Sandroni, C., Cariou, A., Cronberg, T., D’Arrigo, S., Haywood, K., Hoedemaekers, A., Lilja, G., Nikolaou, N., Olasveengen, T., Robba, C., Skrifvars, M., Swindell, P. and Soar, J. (2025b). European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2025: post-resuscitation care.
  5. Desch, S., Freund, A., Akin, I., Behnes, M., Preusch, M., Zelniker, T., Skurk, C., Landmesser, U., Graf, T., Eitel, I., Fuernau, G., Haake, H., Nordbeck, P., Hammer, F., Felix, S., Hassager, C., Engstrom, T., Fichtlscherer, S., Ledwoch, J., Lenk, K., Joner, M., Steiner, S., Liebetrau, C., Voigt, I., Zeymer, U., Brand, M., Schmitz, R., Horstkotte, J., Jacobshagen, C., Poss, J., Abdel-Wahab, M., Lurz, P., Jobs, A., De Waha-Thiele, S., Olbrich, D., Sandig, F., Konig, I., Brett, S., Vens, M., Klinge, K. and Thiele, H. (2021). Angiography after out-of-hospital cardiac arrest without ST-segment elevation. New England Journal of Medicine.
  6. Desch, S., Freund, A., Behnes, M., Preusch, M., Zelniker, T., Landmesser, U., Graf, T., Eitel, I., Haake, H., Nordbeck, P., Hammer, F., Felix, S., Hassager, C., Fichtlscherer, S., Lenk, K., Joner, M., Steiner, S., Liebetrau, C., Voigt, I., Brand, M., Schmitz, R., Horstkotte, J., Poss, J., Abdel-Wahab, M., Lurz, P., Jobs, A., Olbrich, D., Sandig, F., Konig, I., Brett, S., Vens, M., Klinge, K. and Thiele, H. (2023). Coronary angiography after out-of-hospital cardiac arrest without ST-segment elevation. JAMA Cardiology.
  7. Hauw-Berlemont, C., Lamhaut, L., Diehl, J., Andreotti, C., Varenne, O., Leroux, P., Lascarrou, J., Guerin, P., Loeb, T., Roupie, E., Daubin, C., Beygui, F., Boissier, F., Marjanovic, N., Christiaens, L., Vilfaillot, A., Glippa, S., Prat, J., Chatellier, G., Cariou, A. and 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.
  8. European Society of Cardiology (2026). Should patients with an out-of-hospital cardiac arrest and without an ECG ST-elevation receive immediate coronary angiography?
  9. European Society of Cardiology (2026a). DISCO trial: Acute coronary angiography after resuscitated out-of-hospital cardiac arrest without ST-elevation on the ECG.
  10. European Society of Cardiology (2026a). CAG after OHCA without ST-elevation.
  11. Elfwén, L., Lagedal, R., Nordberg, P., James, S., Oldgren, J., Böhm, F., Lundgren, P., Rylander, C., Van Der Linden, J., Hollenberg, J., Erlinge, D., Cronberg, T., Jensen, U., Friberg, H., Lilja, G., Larsson, I., Wallin, E., Rubertsson, S. and Svensson, L. (2019). Direct or subacute coronary angiography in out-of-hospital cardiac arrest (DISCO)—an initial pilot study of a randomized clinical trial.
  12. Freund, A., Van Royen, N., Kern, K., Jobs, A., Thiele, H., Lemkes, J., Desch, S. and TOMAHAWK investigators (2022). Early coronary angiography in patients after out-of-hospital cardiac arrest without ST-segment elevation: Meta-analysis of randomized controlled trials. Catheterization and Cardiovascular Interventions.
  13. Kern, K., Radsel, P., Jentzer, J., Seder, D., Lee, K., Lotun, K., Janardhanan, R., Stub, D., Hsu, C. and Noc, M. (2020). Randomized pilot clinical trial of early coronary angiography versus no early coronary angiography after cardiac arrest without ST-segment elevation. Circulation.
  14. Lemkes, J., Janssens, G., Van Der Hoeven, N., Jewbali, L., Dubois, E., Meuwissen, M., Rijpstra, T., Bosker, H., Blans, M., Bleeker, G., Baak, R., Vlachojannis, G., Eikemans, B., Van Der Harst, P., Van Der Horst, I., Voskuil, M., Van Der Heijden, J., Beishuizen, A., Stoel, M., Camaro, C., Van Der Hoeven, H., Henriques, J., Vlaar, A., Vink, M., Van Den Bogaard, B., Heestermans, T., De Ruijter, W., Delnoij, T., Crijns, H., Oemrawsingh, P., Gosselink, M., Plomp, K., Magro, M., Elbers, P., Van De Ven, P., Oudemans-Van Straaten, H. and Van Royen, N. (2019). Coronary angiography after cardiac arrest without ST-segment elevation. New England Journal of Medicine.
  15. Nolan, J., Charlton-Webb, J., Dean, P., Hormis, A., McGibbon, P., Mutu-Bodiu, F., O’Brien, D., Reynolds, E., Soar, J., Wragg, V. and Benson Clarke, A. (2025). Post-resuscitation care guidelines.
  16. Spoormans, E., Janssens, G., Van Der Hoeven, N., Jewbali, L., Dubois, E., Meuwissen, M., Rijpstra, T., Bosker, H., Blans, M., Bleeker, G., Baak, R., Vlachojannis, G., Eikemans, B., Van Der Harst, P., Van Der Horst, I., Voskuil, M., Van Der Heijden, J., Beishuizen, A., Stoel, M., Camaro, C., Van Der Hoeven, H., Henriques, J., Vlaar, A., Vink, M., Van Den Bogaard, B., Heestermans, T., De Ruijter, W., Delnoij, T., Crijns, H., Oemrawsingh, P., Gosselink, M., Plomp, K., Magro, M., Elbers, P., Zwinderman, A., Van Royen, N. and Lemkes, J. (2026). Immediate vs delayed coronary angiography after cardiac arrest without ST-segment elevation: 5-year outcomes from the COACT randomized trial. Journal of the American College of Cardiology.
  17. Spoormans, E., Thevathasan, T., Van Royen, N., Zwinderman, A., Freund, A., Thiele, H., Ziesemer, K., Desch, S. and Lemkes, J. (2025). One-year outcomes of coronary angiography after out-of-hospital cardiac arrest without ST elevation: An individual patient data meta-analysis. JAMA Cardiology.
  18. Verma, B., Sharma, V., Shekhar, S., Kaur, M., Khubber, S., Bansal, A., Singh, J., Ahuja, K., Nazir, S., Chetrit, M., Menon, V., Reed, G. and Kapadia, S. (2020). Coronary angiography in patients with out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis. JACC: Cardiovascular Interventions.

Educational disclaimer. This update discusses evidence relevant to prehospital practice. It does not replace local clinical guidelines, organisational policy, individual clinical judgement or appropriate senior clinical advice.