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BACKGROUND: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear.
METHODS: In this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days.
RESULTS: A total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P = 0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups.
CONCLUSIONS: Among patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause. (Funded by the German Center for Cardiovascular Research; TOMAHAWK ClinicalTrials.gov number, NCT02750462.).
The findings concur with those of the COACT trial - that early coronary angiography is not superior to delayed angiography for people with cardiac arrest of suspected coronary origin but no ST elevation. The data may even suggest some evidence of harm with early angiography. This is important evidence to support current guidelines and practice.
In this TOMAHAWK trial, the authors presented no clinical difference in 30-day mortality between emergent catheterization and delayed or elective catheterization to assess CAD in NSTE-OHCA. CAD severity between the groups were not significant and may support emergent catheterization in case of OHCA according to patient status. In a busy clinical setting, this could avoid useless procedures that could be harmful.
This is an important result as it means that unless there are ECG changes, rushing off to angio (and the potential risk to the kidneys) is not worth it!
This is a worthwhile article to review. It's reassuring that the patient outcome is not foreseeably negatively impacted by delaying Coronary Angiogram; thereby, allowing time to assess for degree of neurologic recovery etc.
It may be reasonable to stabilize patients after out-of-hospital cardiac arrest if there are no ST elevations for overall improvement in clinical outcomes.