Age- and sex-specific impact of coronary angiography on clinical outcomes in successfully resuscitated out-of-hospital cardiac arrest patients without ST-segment elevation

Background Previous randomized clinical trials have shown that routine urgent coronary angiography (CAG) in patients successfully resuscitated after out-of-hospital cardiac arrest without ST-segment elevation (NSTE-OHCA) does not significantly improve overall prognosis. However, the influence of age- and sex-related disparities on the clinical effectiveness of CAG in this population remains insufficiently investigated. Objective Given that staged or selective CAG is frequently performed in patients perceived to have a favorable prognosis—thereby introducing selection bias—we sought to evaluate the association between in-hospital CAG and neurological outcomes using an adjusted cohort, with particular emphasis on age- and sex-related differences. Methods Of 3,523 OHCA patients transferred to a tertiary critical care center between January 2015 and December 2023, 322 patients who achieved return of spontaneous circulation (ROSC) and exhibited non–ST-segment elevation on post-resuscitation electrocardiography were included. CAG was performed in 188 patients (58.4%). Propensity score matching was used to adjust for confounders influencing CAG indication, including civilian witness status, bystander cardiopulmonary resuscitation, initial shockable rhythm, and prior coronary artery disease. Patients were stratified by age (15–49 vs. ≥50 years) and sex. Neurological outcomes at 30 days and 1 year were assessed using the Cerebral Performance Category (CPC) scale, with favorable neurological status (FNS) defined as CPC 1–2. Results Before adjustment, the CAG group demonstrated a significantly higher proportion of FNS at both 30 days and 1 year across all age and sex cohorts regardless of age and sex. After PS matching, age-stratified analysis revealed that CAG was significantly associated with improved FNS in the elderly group at both 30 days (OR 2.81, 95% CI 1.30–6.09; P<0.01) and 1 year (OR 3.29, 95% CI 1.31–8.27; P=0.011). In contrast, no statistically significant benefit of CAG was observed in the young group at 30 days (OR 3.33, 95% CI 0.69–16.0; P=0.133) or 1 year (OR 3.24, 95% CI 0.69–15.2; P=0.136). In sex-based analyses, CAG was significantly associated with improved FNS in male patients at both 30 days (OR 3.55, 95% CI 1.53–8.21; P<0.01) and 1 year (OR 4.03, 95% CI 1.45–11.2; P<0.01). In female patients, however, the association between CAG and favorable neurological outcomes was not statistically significant at either 30 day (OR 1.86, 95% CI 0.52–6.61; P=0.339) or 1 year (OR 3.00, 95% CI 0.79–11.4; P=0.108). Conclusions In an adjusted cohort of NSTE-OHCA patients, in-hospital CAG was associated with significantly better neurological outcomes in elderly and male patients, but not in younger or female patients. These findings indicate that the clinical benefit of CAG in NSTE-OHCA is heterogeneous and substantially influenced by demographic factors.