Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation
Authors: Desch Steffen , Freund Anne , Akin Ibrahim , Behnes Michael , Preusch Michael R. , Zelniker Thomas A. , Skurk Carsten , Landmesser Ulf , Graf Tobias , Eitel Ingo , Fuernau Georg , Haake Hendrik , Nordbeck Peter , Hammer Fabian , Felix Stephan B. , Hassager Christian , Kjærgaard Jesper , Fichtlscherer Stephan , Ledwoch Jakob , Lenk Karsten , Joner Michael , Steiner Stephan , Liebetrau Christoph , Voigt Ingo , Zeymer Uwe , Brand Michael , Schmitz Roland , Horstkotte Jan , Jacobshagen Claudius , Pöss Janine , Abdel-Wahab Mohamed , Lurz Philipp , Jobs Alexander , de Waha Suzanne , Olbrich Denise , Sandig Frank , König Inke R. , Brett Sabine , Vens Maren , Klinge Kathrin , Thiele Holger ,   TOMAHAWK Investigators, Ansari Uzair , Stiepak Jan , Schmoll Karolin , Stiermaier Thomas , Wurster Thomas , Knie Wulf , vom Dahl Jürgen , Kotzlowski Christian , Maniuc Octavian , Moritz Maria , Abel Peter , Beug Daniel , Engstrøm Thomas , Vasa-Nicotera Mariuca , Heyl Stephan , Kupatt Christian , Hoppmann Petra , Bradaric Christian , Laufs Ulrich , Lavall Daniel , Mayr Patrick , Lahmann Anna-Lena , Weigel Stefanie , Weferling Maren , Hamm Catharina , Schmitz Thomas , Winkler Ralph , Trappe Hans-Joachim , Valina Christian , Schöchlin Simon , Garlichs Christoph , Seidler Tim , Hasenfuß Gerd , Otto Sylvia , Möbius-Winkler Sven , Schulze P Christian , Gori Tommaso , Kische Stephan , Grewe Peter , Pels Klaus , Sack Stefan , Mudra Harald , Menck Niels , Klöppner Norman , Löser Stefan , Lauten Philipp , Linke Axel , Mangner Norman , Woitek Felix , Frank Derk , Lutz Matthias , Frey Norbert , Geisler Tobias , Droppa Michal , Ohlow Marc-Alexander 
Published: August 2023

Importance

Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear.

Objective

To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up.

Design, Setting, and Participants

The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death.

Interventions

Early vs delayed or selective coronary angiography and revascularization if indicated.

Main Outcomes and Measures

Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year.

Results

A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups.

Conclusions and Relevance

This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02750462