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. 2023 Sep 1;8(9):827-834.
doi: 10.1001/jamacardio.2023.2264.

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial

Steffen Desch  1   2   3   4 , Anne Freund  1   2   4 , Ibrahim Akin  4   5 , Michael Behnes  4   5 , Michael R Preusch  4   6 , Thomas A Zelniker  4   6   7 , Carsten Skurk  4   8 , Ulf Landmesser  4   8 , Tobias Graf  3   4 , Ingo Eitel  3   4 , Georg Fuernau  9 , Hendrik Haake  10 , Peter Nordbeck  11 , Fabian Hammer  4   12 , Stephan B Felix  4   12 , Christian Hassager  13   14 , Jesper Kjærgaard  13   14 , Stephan Fichtlscherer  4   15 , Jakob Ledwoch  4   16 , Karsten Lenk  17 , Michael Joner  4   18 , Stephan Steiner  19 , Christoph Liebetrau  4   20 , Ingo Voigt  21   22 , Uwe Zeymer  23 , Michael Brand  24 , Roland Schmitz  25 , Jan Horstkotte  26 , Claudius Jacobshagen  4   27   28 , Janine Pöss  1 , Mohamed Abdel-Wahab  1 , Philipp Lurz  1 , Alexander Jobs  1   2   3   4 , Suzanne de Waha  29 , Denise Olbrich  4   30 , Frank Sandig  4   31 , Inke R König  4   31 , Sabine Brett  4   30 , Maren Vens  4   31 , Kathrin Klinge  4   30 , Holger Thiele  1   2 ; TOMAHAWK Investigators
Collaborators, Affiliations

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial

Steffen Desch et al. JAMA Cardiol. .

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Desch reported receiving grants from the DZHK (German Center for Cardiovascular Research) during the conduct of the study. Dr Freund reported receiving grants from the DZHK during the conduct of the study. Dr Zelniker reported receiving grants from the Austrian Science Fund (FWF) and German Research Foundation (DFG); personal fees from Boehringer Ingelheim, Alkem Laboratories, AstraZeneca, Bayer AG, and Sun Pharmaceutical Industries; and educational grants from Eli Lilly outside the submitted work. Dr Hassager reported receiving grants from the Lundbeck Foundation and lecture honoraria from Abiomed during the conduct of the study. Dr Joner reported receiving personal fees from Abbott, Alchimedics SAS, AstraZeneca, Biotronik, Boston Scientific, Cardiac Dimensions, Edwards, ReCor Medical, Shockwave, TriCare, and Veryan; and grants from Boston Scientific, Cardiac Dimensions, Edwards, and Infraredx outside the submitted work. Dr Steiner reported receiving grants from the DZHK during the conduct of the study. Dr Liebetrau reported receiving personal fees from AstraZeneca, Bayer, Daiichi Sankyo, and Boehringer Ingelheim outside the submitted work. Dr Zeymer reported receiving personal fees from AstraZeneca, Bayer, Boehringer Ingelheim, Pfizer, Novartis, and ZOLL; and grants from BMS and Ferrer outside the submitted work. Dr Pöss reported receiving grants from the German Cardiac Society, the German Heart Research Foundation, and the Dr Rolf M. Schwiete Foundation outside the submitted work. Dr Abdel-Wahab reported receiving personal fees from Medtronic, Boston Scientific, and Abbott paid to his institution outside the submitted work. Dr Lurz reported receiving grants from ReCor Medical and Abbott Medical and personal fees from Innoventric outside the submitted work. Dr de Waha reported receiving grants from the DZHK during the conduct of the study and personal fees from ZOLL TherOx outside the submitted work. Dr Olbrich reported receiving grants from the Center for Clinical Trials, University Lübeck during the conduct of the study. Dr König reported receiving grants from the German Center for Cardiovascular Research during the conduct of the study. Dr Brett reported receiving grants from the Center for Clinical Trials, Universitaetsklinikum Schleswig Holstein, Campus Luebeck during the conduct of the study. Dr Klinge reported receiving grants from the Center for Clinical Trials, University of Lübeck during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flowchart for the Intention-to-Treat Population
STEMI indicates ST-segment elevation myocardial infarction.
Figure 2.
Figure 2.. All-Cause Mortality End Point
Event rates indicate Kaplan-Meier estimates.
Figure 3.
Figure 3.. Forest Plot of the End Point 1-Year All-Cause Mortality in Prespecified Subgroups
MI indicates myocardial infarction; OHCA, out-of-hospital cardiac arrest; and ROSC, return of spontaneous circulation.
See this image and copyright information in PMC

Comment in

References

    1. Yan S, Gan Y, Jiang N, et al. . The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care. 2020;24(1):61. doi:10.1186/s13054-020-2773-2 - DOI - PMC - PubMed
    1. Grunau B, Kime N, Leroux B, et al. . Association of intra-arrest transport vs continued on-scene resuscitation with survival to hospital discharge among patients with out-of-hospital cardiac arrest. JAMA. 2020;324(11):1058-1067. doi:10.1001/jama.2020.14185 - DOI - PMC - PubMed
    1. Geri G, Passouant O, Dumas F, et al. . Etiological diagnoses of out-of-hospital cardiac arrest survivors admitted to the intensive care unit: insights from a French registry. Resuscitation. 2017;117:66-72. doi:10.1016/j.resuscitation.2017.06.006 - DOI - PubMed
    1. Ibanez B, James S, Agewall S, et al. ; ESC Scientific Document Group . 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. doi:10.1093/eurheartj/ehx393 - DOI - PubMed
    1. Dumas F, Cariou A, Manzo-Silberman S, et al. . Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-207. doi:10.1161/CIRCINTERVENTIONS.109.913665 - DOI - PubMed

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