TOMAHAWK: immediate angiography after out-of-hospital cardiac arrest without ST-segment elevation
Reported from the European Society of Cardiology ESC Congress 2021
Rationale
The clinical rationale behind the TOMAHAWK trial was to address the hypothesis that routine immediate coronary angiography is superior to a deferred or selective approach regarding 30-day all-cause mortality in resuscitated patients with out-of-hospital cardiac arrest (OHCA) without ST-segment elevation.
Here are the basic facts of the TOMAHAWK trial that was simultaneously published in the NEJM.
How was the study performed?
A multicenter trial with 554 patients with successfully resuscitated out-of-hospital cardiac arrest who were randomized. All the patients had no evidence of ST-segment elevation on post-resuscitation electrocardiography.
Population:
A total of 256 patients were included in the primary analysis in each group - either immediate coronary angiography or initial intensive care assessment with delayed or selective angiography.
Intervention:
Immediate-angiography vs. delayed-angiography (admission to the intensive care unit; coronary angiography after a minimum delay of 24 hours after cardiac arrest).
Outcomes:
At 30 days, 54.0 % in the immediate-angiography group and 46.0 % in the delayed-angiography group had died (HR-1.28; P = 0.06).
The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group than in the delayed-angiography group (64.3 % vs. 55.6 %; RR -1.16; (95 % CI, 1.00 to 1.34)
Time:
Follow-up duration was 30-day.
Interpretation
The TOMAHAWK trial found that among patients with resuscitated (OHCA) with a possible cardiac cause without ST-segment elevation, an immediate coronary angiography strategy was not found to be beneficial over a delayed or selective strategy with respect to the 30-day risk of death from any cause.
The current findings support the results from the randomized Coronary Angiography after Cardiac Arrest (COACT) trial, which also showed no significant differences in clinical outcome among patients with OHCA between immediate and delayed coronary angiography at 90 days and at 1 year.
It should be noted that the COACT trial enrolled only patients with a shockable arrest rhythm, while the TOMAHAWK trial recruited patients with both shockable and non-shockable rhythms, thereby extending the findings to a broader spectrum of risk.
-> What is your approach regarding the timing of coronary angiography after cardiac arrest in patients without ST-Segment elevation in daily practice?
TOMAHAWK trial, no benefit for early angiography. Similar results as the COACT trial, but also included nonshockable rhythm. What is your approach? @mirvatalasnag@BiascoDr@DanieleGiacoppo@DrPascalMeier@VijayKunadian@ANazmiCalik@MilasinD18@Ortega_Paz@NicolaRyanI1pic.twitter.com/22igNyLq8Z
— Elad Asher (@AsherElad) August 29, 2021
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