Myocardial infarction, commonly known as a heart attack, often leads to out-of-hospital cardiac arrest (OHCA). A recent multicenter trial, the TOMAHAWK trial published in JAMA Cardiology by Steffen Desch and colleagues, sought to determine whether early unselective coronary angiography provides better clinical outcomes for successfully resuscitated OHCA patients with suspected cardiac origins but no ST-segment elevation. The study aimed to compare the effectiveness of an immediate angiography approach with a delayed or selective strategy.

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The TOMAHAWK trial, conducted across Germany and Denmark, was an investigator-initiated randomized clinical trial. Between November 2016 and September 2019, 554 patients who experienced OHCA of pJAMA
Cardiologyresumed cardiac origin, without ST-segment elevation, were enrolled. Patients with stable return of spontaneous circulation after resuscitation were included. Participants were randomized into two groups: immediate coronary angiography after hospital admission or a delayed/selective angiography approach after a minimum of 24 hours. Survival analyses and secondary clinical outcomes were assessed over a 1-year follow-up period.
● Of the 554 participants, 281 underwent immediate angiography, while 273 were assigned to delayed/selective angiography.

● At the end of the 1-year follow-up, the all-cause mortality rate was 60.8% in the immediate angiography group and 54.3% in the delayed/selective group, with no statistically significant difference between the two strategies.
● The hazard ratio for mortality was 1.25 (95% CI, 0.99-1.57; P = .05), indicating a trend towards increased mortality with immediate angiography.
● Among patients who survived to 1 year, both groups exhibited similar rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure.
The TOMAHAWK trial findings suggest that there is no clear clinical benefit to adopting an immediate coronary angiography strategy over a delayed/selective approach for patients who experience resuscitated OHCA with suspected coronary causes but no ST-segment elevation. The study underscores the need for a careful evaluation of treatment strategies for this patient population. While the results do not completely dismiss the possibility of benefits from immediate angiography, the data suggests that both approaches yield comparable outcomes in terms of survival and secondary clinical outcomes over a 1-year period.
Reference:
Desch, S., Freund, A., Akin, I., Behnes, M., Preusch, M. R., Zelniker, T. A., Skurk, C., Landmesser, U., Graf, T., Eitel, I., Fuernau, G., Haake, H., Nordbeck, P., Hammer, F., Felix, S. B., Hassager, C., Kjærgaard, J., Fichtlscherer, S., Ledwoch, J., … TOMAHAWK Investigators. (2023). Coronary angiography after out-of-hospital cardiac arrest without ST-segment elevation: One-year outcomes of a randomized clinical trial. JAMA Cardiology. https://doi.org/10.1001/jamacardio.2023.2264