Cardiac arrest without ST-elevation: instant angiogram does not improve mortality

Immediate versus delayed angiography in survivors of an out-of-hospital cardiac arrest (OHCA) was assessed within the TOMAHAWK study. The results failed to determine an advantage of the early procedure on 30-day all-cause mortality [1,2].

About 2 third of resuscitated OHCA patients without primarily obvious non-cardiac pathology do not present ST-elevation on the ECG [3]. Pros and cons of an instant coronary angiogram in these patients are still under debate [1,2]. The TOMAHAWK study (NCT02750462) hypothesised that the unselected immediate angiogram would be advantageous for OHCA patients compared with a delayed/selective angiogram. The trial randomised 554 patients over 30 years of age from various sites in Germany and Denmark who met the inclusion criteria of documented OHCA with return of spontaneous circulation (ROSC). ST-elevation in the ECG was among the reasons for exclusion. The primary endpoint was defined as all-cause mortality at 30 days.

The median age in the cohort was 70 years, roughly 38% had a prior diagnosis of coronary artery disease, and more than 50% presented a shockable first monitored rhythm. The timespan from OHCA to return ROSC was 15 min in both study groups. In the immediate group, 95.5% received an angiogram that was performed within 3 hours after OHCA, while 62.2% of the delayed group patients were taken to the Cath lab at a median of 46.9 hours after their arrest.

Overall, there was no significant difference between the arms in the primary endpoint (HR 1.28; 95% CI 1.00–1.63). “If you take the composite of all-cause mortality or severe neurological deficit, this actually becomes statistically significant, yet not accounted for multiple testing; so, this is just hypothesis generating,” Prof. Steffen Desch (University Heart Center Lübeck, Germany) highlighted one of the key secondary outcomes. Several relevant subgroups were also assessed without reaching statistical significance.

Although this has to be considered a neutral trial, discussant Prof. Susanna Price (Royal Brompton Hospital, UK) stressed that it answered an important question [4]. “It gives me information that is useful regarding the opportunity to minimise harm, which is a lot of what critical care is about. So, we do not necessarily have to move these patients very acutely when they just come into the ED. This has implications for resource utilisation, but it also has implications for mobilising patients around the hospital during COVID 19,” she underlined.

1. 
   
   1. Desch S. TOMAHAWK: Immediate angiography after out-of-hospital cardiac arrest. Hot Line Session, ESC Congress 2021, 27–30 August.
   2. Desch, S. N Engl J Med 2021;29 Aug. DOI:1056/NEJMoa2101909.
   3. Dumas F, et al. Circ Cardiovasc Interv. 2010;3(3):200-207.
   4. Price S. TOMAHAWK – Discussant review. Hot Line Session, ESC Congress 2021, 27–30 August.

 

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Posted on 26 October, 2021