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

ImportanceMyocardial 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.ObjectiveTo 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 ParticipantsThe 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.InterventionsEarly vs delayed or selective coronary angiography and revascularization if indicated.Main Outcomes and MeasuresEvaluations 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.ResultsA 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 RelevanceThis 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 RegistrationClinicalTrials.gov Identifier: NCT02750462