TOMAHAWK Trial: Immediate Angiography After Cardiac Arrest Without ST Elevation Shows No Benefit
This landmark multicenter RCT randomized 554 resuscitated out-of-hospital cardiac arrest patients without ST-segment elevation to immediate versus delayed coronary angiography. At 30 days, immediate angiography showed no mortality benefit (54.0% vs 46.0%, HR 1.28, p=0.06) and the composite of death or severe neurologic deficit was numerically worse. The trial established that a selective, ICU-first strategy is appropriate for this population, fundamentally changing post-arrest care protocols.
The original study
Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation.
- Authors
- Desch S, Freund A, Akin I, Behnes M, Preusch MR, Zelniker TA, et al.
- Journal
- The New England journal of medicine
- Type
- Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't
- PMID
- 34459570
Original abstract
BACKGROUND: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear. METHODS: In this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days. RESULTS: A total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P = 0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups. CONCLUSIONS: Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause. (Funded by the German Center for Cardiovascular Research; TOMAHAWK ClinicalTrials.gov number, NCT02750462.).