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Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a
Steffen Desch1,2,3,4, Anne Freund1,2,4, Ibrahim Akin4,5
1Heart Center Leipzig at the University of Leipzig, Department of Internal Medicine/Cardiology, University of Leipzig, Leipzig, Germany.
Insights
Immediate coronary angiography did not improve outcomes for out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation. A delayed or selective approach showed similar 1-year mortality and clinical benefits, suggesting no advantage to early invasive procedures.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Trials
Background:
- Myocardial infarction is a leading cause of out-of-hospital cardiac arrest (OHCA).
- The long-term impact of early coronary angiography in OHCA patients with suspected coronary triggers but no ST-segment elevation is not well-established.
Purpose of the Study:
- To compare 1-year clinical outcomes between immediate and delayed/selective coronary angiography in OHCA patients without ST-segment elevation.
- To assess the efficacy of early versus later invasive cardiac procedures in this patient population.
Main Methods:
- The TOMAHAWK trial randomized 554 OHCA patients without ST-segment elevation to immediate or delayed/selective coronary angiography.
- Follow-up included 1-year all-cause mortality and secondary outcomes like neurologic deficit and reinfarction in survivors.
Main Results:
- One-year all-cause mortality was similar between groups (60.8% immediate vs. 54.3% delayed), with a trend towards higher mortality with immediate angiography (HR 1.25, P=0.05).
- Rates of severe neurologic deficit, myocardial infarction, and heart failure rehospitalization were comparable among survivors in both groups.
Conclusions:
- Immediate coronary angiography offers no clinical benefit over a delayed or selective approach for OHCA patients with presumed cardiac origin but no ST-segment elevation.
- Current findings suggest that a less immediate invasive strategy is appropriate for this patient group.
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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