Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation - TOMAHAWK

Aug 11, 2023
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Author/Summarized by Author:
Anthony A. Bavry, MD, MPH, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC; Kim A. Eagle, MD, MACC
Trial Sponsor:
German Center for Cardiovascular Research
Date Presented:
08/28/2022
Date Published:
08/09/2023
Date Updated:
08/11/2023
Original Posted Date:
08/29/2021
References

Contribution To Literature:

Highlighted text has been updated as of August 11, 2023.

The TOMAHAWK trial failed to show that early coronary angiography was beneficial to initial intensive care management among patients with out-of-hospital cardiac arrest.

Description:

The goal of the trial was to evaluate early coronary angiography compared with initial intensive care management with delayed/selective coronary angiography among patients who suffered an out-of-hospital cardiac arrest of possible coronary origin.

Study Design

  • Randomization
  • Parallel

Participants with out-of-hospital cardiac arrest of possible coronary origin were randomized to early coronary angiography (n = 265) versus initial intensive care management with delayed/selective coronary angiography (n = 265).

  • Total number of enrollees: 530
  • Duration of follow-up: 12 months
  • Median patient age: 70 years
  • Percentage female: 30.4%
  • Percentage with diabetes: 29%

Inclusion criteria:

  • At least 30 years old
  • Out-of-hospital cardiac arrest and return of spontaneous circulation
  • No ST-segment elevation on post-resuscitation electrocardiography

Exclusion criteria:

  • ST-segment elevation myocardial infarction or left bundle branch block
  • Severe hemodynamic/electrical instability requiring immediate coronary angiography
  • Obvious extracardiac etiology
  • Known or suspected pregnancy
  • Participation in another interventional study

Principal Findings:

The primary outcome, all-cause mortality at 30 days, was 54.0% in the early coronary angiography group compared with 46.0% in the initial intensive care management group (p = 0.06).

Secondary outcomes:

  • Death or severe neurologic deficit: 64.3% in the early coronary angiography group compared with 55.6% in the initial intensive care management group

12-month outcomes:

  • All-cause death: 60.8% in the early coronary angiography group vs. 54.3% in the initial intensive care group
  • Severe neurologic deficit: 13.5% in the early coronary angiography group vs. 9.2% in the initial intensive care group

Interpretation:

Among patients with out-of-hospital cardiac arrest of possible coronary origin, a strategy of early coronary angiography was not beneficial compared to initial intensive care management with delayed/selective coronary angiography. Early coronary angiography did not improve 30-day survival, or death/severe neurologic deficit. The lack of treatment benefit with early coronary angiography was also observed at 12 months.

References:

Desch S, Freund A, Akin I, et al. Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial. JAMA Cardiol 2023;Aug 9:[Epub ahead of print].

Editorial Comment: Pareek N, Keeble TR, Banerjee S. Out-of-Hospital Cardiac Arrest—One Size Does Not Fit All. JAMA Cardiol 2023;Aug 9:[Epub ahead of print].

Presented by Dr. Steffen Desch at the European Society of Cardiology Congress (ESC 2022), Barcelona, Spain, August 28, 2022.

Desch S, Freund A, Akin I, et al., on behalf of the TOMAHAWK Investigators. Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation. N Engl J Med 2021;385:2544-53.

Presented by Dr. Steffen Desch at the European Society of Cardiology Virtual Congress, August 29, 2021.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: ESC22, ESC21, ESC Congress, Acute Coronary Syndrome, Arrhythmias, Cardiac, Coronary Angiography, Coronary Vessels, Critical Care, Electrocardiography, Heart Arrest, Heart Failure, Neurology, Out-of-Hospital Cardiac Arrest, Secondary Prevention


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