Coronary angiography after out-of-hospital cardiac arrest without ST-segment elevation not associated with an improvement in clinical outcomes

1. There was no disparity in one-year all-cause mortality between the immediate angiography group and a strategy where angiography was postponed for at least 24 hours or abandoned for patients who suffered an out-of-hospital cardiac arrest (OHCA) due to a presumed cardiac cause but without ST-segment elevation.

2. Among patients who survived up to one year, there were no significant differences in the rates of severe neurological deficit, myocardial infarction, and rehospitalization due to congestive heart failure between the groups.

Evidence Rating Level: 1 (Excellent)

Study Rundown: With OHCA’s poor survival rates and substantial post-resuscitation mortality, urgent coronary angiography and revascularization have been proposed for cases linked to acute coronary syndromes, notably with ST-segment elevation. In the context of OHCA patients lacking ST-segment elevation, debates persist over when and whether to proceed with coronary angiography due to the diverse underlying causes. The TOMAHAWK trial showed that immediate coronary angiography and delayed/selective strategies had similar 30-day all-cause mortality outcomes for resuscitated OHCA patients without ST-segment elevation. This study sought to present the one-year results to provide a broader perspective with longer-term follow-up. Like the initial investigation, there was no significant difference in the one-year all-cause mortality between immediate and delayed or selective coronary angiography for patients following resuscitated OHCA with a presumed cardiac cause and without ST-segment elevation. The lack of blinding to treatment randomization for physicians and intensive care unit staff introduces a potential limitation. This matters because OHCA management requires intricate clinical judgments, and the absence of blinding could lead to residual bias in decision-making, potentially affecting the study’s reliability and validity. In conclusion, these findings question the traditionally held notion that an immediate invasive approach is advantageous for this group of patients.

Click to read the study in JAMA Cardiology

Click to read an accompanying editorial in JAMA Cardiology

Relevant Reading: Coronary Angiography after Cardiac Arrest without ST-Segment Elevation

In-Depth [randomized controlled trial]: This study sought to perform a one-year analysis following the patients from the TOMAHAWK trial, a multicenter, international, investigator-initiated, open-label, randomized clinical trial that included 554 participants between 23, 2016 to September 20, 2019. Eligible participants were patients aged 30 years or above who experienced resuscitated OHCA presumed to be cardiac in origin, had return of spontaneous circulation without ST-segment elevation, and presented with both shockable and non-shockable arrest rhythms; those with hemodynamic or electrical instability were excluded from the study. The one-year analysis reports outcomes for predefined secondary endpoints, including all-cause mortality, severe neurologic deficit, myocardial infarction, and rehospitalization due to congestive heart failure. In the immediate angiography group, all-cause mortality was 60.8%, while in the delayed or selective angiography group, it was 54.3%, with no definitive difference between the strategies; there was a slight trend towards higher mortality with immediate angiography (hazard ratio (HR): 1.25; 95% CI: 0.99-1.57; log-rank P = 0.05), consistently observed across predefined subgroups. Between 30 days and 1 year, there was no disparity in all-cause mortality between the treatment groups (relative risk (RR): 0.95; 95% CI: 0.54-1.67).

Image: PD

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