Results of the multicenter TOMAHAWK trial presented at the European Society Congress (ESC) Congress 2021 do not show advantage of early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients with no evidence of ST-segment elevation compared to a delayed or selective approach.

The trial included 554 patients out-of-hospital cardiac arrest, with shockable and nonshockable arrest rhythm, who had been successfully resuscitated. These patients were then randomly subjected to either immediate coronary angiography or intensive care and delayed or selective angiography after an average delay of 2 days. ECG done after resuscitation showed no ST-segment elevation in any of the study participants. The primary objective of the trial was to evaluate all-cause mortality at 30 days in both the study groups.

Mortality at 30 days was 54% in patients who underwent immediate angiography, while the mortality was 46% in the delayed angiography group (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P=0.06).

The secondary outcome measure was a composite of death from any cause or severe neurologic deficit at 30 days. More patients in the immediate angiography group met the secondary end point at 30 days vs delayed angiography group; 64.3% vs 55.6%, respectively.

No between-group differences were observed for length of ICU stay, peak troponin release, myocardial infarction or rehospitalisation for congestive heart failure or safety endpoints such as stroke, bleeding or kidney failure necessitating dialysis.

Hence, based on these findings, the study concluded that performing immediate angiography in these patients offers no benefit more than the delayed or selective angiography in terms of all-cause mortality at 30 days.

Source: Angiography after out-of-hospital cardiac arrest without ST-segment elevation. New Engl J Med. August 29, 2021, DOI: 10.1056/NEJMoa2101909; ESC News Release, August 29, 2021