Performing immediate coronary angiography in patients with resuscitated out-of-hospital cardiac arrest (OHCA) without ST-segment elevation provided no benefit over a delayed/selective approach with respect to 30-day risk of death from any cause, according to findings from the TOMAHAWK trial presented at ESC Congress 2021 and published in the New England Journal of Medicine.

The multicenter trial randomized 554 patients with successfully resuscitated OHCA and evidence of ST-segment elevation to either immediate coronary angiography or initial intensive care assessment with delayed or selective angiography. The primary end point was death from any cause at 30 days, while secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days.

At 30 days, 143 of 265 patients (54%) in the immediate-angiography group compared with 122 of 265 patients (46%) in the delayed-angiography group had died. The secondary endpoints occurred more frequently in the immediate angiography group (64.3%) than in the delayed-angiography group (55.6%), for a relative risk of 1.16 – a finding that principal investigator Steffen Desch, MD, noted is "hypothesis generating." Results from other values, such as length of ICU stay, peak troponin release, myocardial infarction or rehospitalization for congestive heart failure did not differ between groups. Additionally, there were no differences between groups in safety endpoints including moderate or severe bleeding, stroke and acute renal failure requiring renal replacement therapy.

"TOMAHAWK was the second and largest randomized trial addressing the question of early coronary angiography in OHCA patients without ST-segment elevation," said Desch. "Like the COACT trial we found that early angiography was not superior to a delayed/selective approach. COACT was restricted to patients with shockable rhythm and TOMAHAWK extends the findings to patients with non-shockable rhythm." He added that "the results of the trial [also] suggest that patients without a significant coronary lesion as the trigger of cardiac arrest do not benefit from an invasive approach and might even be harmed."

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: ESC Congress, ESC21, Coronary Angiography, Percutaneous Coronary Intervention, Acute Coronary Syndrome, ACC International

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