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