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Hot Line - No benefit of immediate coronary angiography in patients with cardiac arrest without ST elevation

29 Aug 2021
Hot Line presented at ESC Congress

The usefulness and timing of coronary angiography in out-of-hospital cardiac arrest (OHCA) survivors without ST-segment elevation are uncertain. ESC guidelines recommend considering delayed angiography among haemodynamically stable patients without ST-segment elevation successfully resuscitated after OHCA1 based on the COACT trial, which found that an unselected immediate invasive strategy was not superior to a delayed invasive strategy in patients with shockable rhythm.2

In a Hot Line session today, Professor Steffen Desch (University of Leipzig, Germany) presented results from the large randomised, open-label TOMAHAWK trial, which undertook to provide a definitive position on the use of early angiography in patients with shockable or non-shockable rhythm.

The trial randomised 554 patients with return of spontaneous circulation after OHCA with no obvious extracardiac origin of cardiac arrest and no ST-segment elevation/left bundle-branch block on post-resuscitation electrocardiogram to either immediate coronary angiography or initial intensive care unit (ICU) assessment with delayed/selective angiography in a 1:1 ratio. The primary endpoint was all-cause mortality at 30 days.

Immediate coronary angiography did not reduce all-cause mortality, with a 30-day rate of 54% compared with 46% for delayed/selective angiography (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.00 to 1.63; log-rank p=0.058). There were no differences in the primary endpoint between the different approaches in any prespecified subgroups, including patients with shockable vs. non-shockable rhythm.

The composite secondary endpoint of all-cause death or severe neurological deficit at 30 days occurred more frequently in the immediate angiography group compared with the delayed/selective group (relative risk 1.16; 95% CI 1.002 to 1.34).

There were no differences between immediate and delayed/selective angiography in other secondary endpoints, such as length of ICU stay, peak troponin release or myocardial infarction, or in safety endpoints, including moderate or severe bleeding, stroke and acute renal failure requiring renal replacement therapy.

“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,” said Prof. Desch. And he added a note of caution: “In TOMAHAWK, the higher rate of death or severe neurological deficit in the immediate angiography group is only hypothesis-generating. However, the results of the trial 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.”


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1. Collet JP, et al. Eur Heart J. 2021;42:1289–1367.
2. Lemkes JS, et al. N Engl J Med. 2019;380:1397–1407.