Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

Steffen Desch; Anne Freund; Ibrahim Akin; Michael Behnes; Michael R Preusch; Thomas A Zelniker; Carsten Skurk; Ulf Landmesser; Tobias Graf; Ingo Eitel; Georg Fuernau; Hendrik Haake; Peter Nordbeck; Fabian Hammer; Stephan B Felix; Christian Hassager; Thomas Engstrøm; Stephan Fichtlscherer; Jakob Ledwoch; Karsten Lenk; Michael Joner; Stephan Steiner; Christoph Liebetrau; Ingo Voigt; Uwe Zeymer; Michael Brand; Roland Schmitz; Jan Horstkotte; Claudius Jacobshagen; Janine Pöss; Mohamed Abdel-Wahab; Philipp Lurz; Alexander Jobs; Suzanne de Waha-Thiele; Denise Olbrich; Frank Sandig; Inke R König; Sabine Brett; Maren Vens; Kathrin Klinge; Holger Thiele; TOMAHAWK Investigators

doi:10.1056/NEJMoa2101909

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

Steffen Desch, Anne Freund, Ibrahim Akin, Michael Behnes, Michael R Preusch, Thomas A Zelniker, Carsten Skurk, Ulf Landmesser, Tobias Graf, Ingo Eitel, Georg Fuernau, Hendrik Haake, Peter Nordbeck, Fabian Hammer, Stephan B Felix, Christian Hassager, Thomas Engstrøm, Stephan Fichtlscherer, Jakob Ledwoch, Karsten LenkMichael Joner, Stephan Steiner, Christoph Liebetrau, Ingo Voigt, Uwe Zeymer, Michael Brand, Roland Schmitz, Jan Horstkotte, Claudius Jacobshagen, Janine Pöss, Mohamed Abdel-Wahab, Philipp Lurz, Alexander Jobs, Suzanne de Waha-Thiele, Denise Olbrich, Frank Sandig, Inke R König, Sabine Brett, Maren Vens, Kathrin Klinge, Holger Thiele, TOMAHAWK Investigators

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Abstract

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.).

Originalsprog	Engelsk
Tidsskrift	New England Journal of Medicine
Vol/bind	385
Udgave nummer	27
Sider (fra-til)	2544-2553
Antal sider	10
ISSN	0028-4793
DOI	https://doi.org/10.1056/NEJMoa2101909 https://doi.org/10.1056/NEJMoa2101909
Status	Udgivet - 30 dec. 2021

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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., Engstrøm, T., Fichtlscherer, S., Ledwoch, J., ... TOMAHAWK Investigators (2021). Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation. New England Journal of Medicine, 385(27), 2544-2553. https://doi.org/10.1056/NEJMoa2101909, https://doi.org/10.1056/NEJMoa2101909

Desch, S, Freund, A, Akin, I, Behnes, M, Preusch, MR, Zelniker, TA, Skurk, C, Landmesser, U, Graf, T, Eitel, I, Fuernau, G, Haake, H, Nordbeck, P, Hammer, F, Felix, SB, Hassager, C , Engstrøm, T, Fichtlscherer, S, Ledwoch, J, Lenk, K, Joner, M, Steiner, S, Liebetrau, C, Voigt, I, Zeymer, U, Brand, M, Schmitz, R, Horstkotte, J, Jacobshagen, C, Pöss, J, Abdel-Wahab, M, Lurz, P, Jobs, A, de Waha-Thiele, S, Olbrich, D, Sandig, F, König, IR, Brett, S, Vens, M, Klinge, K, Thiele, H & TOMAHAWK Investigators 2021, 'Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation', New England Journal of Medicine, bind 385, nr. 27, s. 2544-2553. https://doi.org/10.1056/NEJMoa2101909, https://doi.org/10.1056/NEJMoa2101909

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title = "Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation",

abstract = "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.).",

keywords = "Aged, Cardiopulmonary Resuscitation, Cause of Death, Coronary Angiography, Coronary Disease/complications, Electrocardiography, Female, Humans, Kaplan-Meier Estimate, Length of Stay, Male, Middle Aged, Nervous System Diseases/etiology, Out-of-Hospital Cardiac Arrest/complications, ST Elevation Myocardial Infarction/diagnostic imaging, Time Factors, Time-to-Treatment",

author = "Steffen Desch and Anne Freund and Ibrahim Akin and Michael Behnes and Preusch, {Michael R} and Zelniker, {Thomas A} and Carsten Skurk and Ulf Landmesser and Tobias Graf and Ingo Eitel and Georg Fuernau and Hendrik Haake and Peter Nordbeck and Fabian Hammer and Felix, {Stephan B} and Christian Hassager and Thomas Engstr{\o}m and Stephan Fichtlscherer and Jakob Ledwoch and Karsten Lenk and Michael Joner and Stephan Steiner and Christoph Liebetrau and Ingo Voigt and Uwe Zeymer and Michael Brand and Roland Schmitz and Jan Horstkotte and Claudius Jacobshagen and Janine P{\"o}ss and Mohamed Abdel-Wahab and Philipp Lurz and Alexander Jobs and {de Waha-Thiele}, Suzanne and Denise Olbrich and Frank Sandig and K{\"o}nig, {Inke R} and Sabine Brett and Maren Vens and Kathrin Klinge and Holger Thiele and {TOMAHAWK Investigators}",

note = "Copyright {\textcopyright} 2021 Massachusetts Medical Society.",

year = "2021",

month = dec,

day = "30",

doi = "10.1056/NEJMoa2101909",

language = "English",

volume = "385",

pages = "2544--2553",

journal = "New England Journal of Medicine",

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TY - JOUR

T1 - Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

AU - Desch, Steffen

AU - Freund, Anne

AU - Akin, Ibrahim

AU - Behnes, Michael

AU - Preusch, Michael R

AU - Zelniker, Thomas A

AU - Skurk, Carsten

AU - Landmesser, Ulf

AU - Graf, Tobias

AU - Eitel, Ingo

AU - Fuernau, Georg

AU - Haake, Hendrik

AU - Nordbeck, Peter

AU - Hammer, Fabian

AU - Felix, Stephan B

AU - Hassager, Christian

AU - Engstrøm, Thomas

AU - Fichtlscherer, Stephan

AU - Ledwoch, Jakob

AU - Lenk, Karsten

AU - Joner, Michael

AU - Steiner, Stephan

AU - Liebetrau, Christoph

AU - Voigt, Ingo

AU - Zeymer, Uwe

AU - Brand, Michael

AU - Schmitz, Roland

AU - Horstkotte, Jan

AU - Jacobshagen, Claudius

AU - Pöss, Janine

AU - Abdel-Wahab, Mohamed

AU - Lurz, Philipp

AU - Jobs, Alexander

AU - de Waha-Thiele, Suzanne

AU - Olbrich, Denise

AU - Sandig, Frank

AU - König, Inke R

AU - Brett, Sabine

AU - Vens, Maren

AU - Klinge, Kathrin

AU - Thiele, Holger

AU - TOMAHAWK Investigators

PY - 2021/12/30

Y1 - 2021/12/30

N2 - 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.).

AB - 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.).

KW - Aged

KW - Cardiopulmonary Resuscitation

KW - Cause of Death

KW - Coronary Angiography

KW - Coronary Disease/complications

KW - Electrocardiography

KW - Female

KW - Humans

KW - Kaplan-Meier Estimate

KW - Length of Stay

KW - Male

KW - Middle Aged

KW - Nervous System Diseases/etiology

KW - Out-of-Hospital Cardiac Arrest/complications

KW - ST Elevation Myocardial Infarction/diagnostic imaging

KW - Time Factors

KW - Time-to-Treatment

UR - http://www.scopus.com/inward/record.url?scp=85120848128&partnerID=8YFLogxK

U2 - 10.1056/NEJMoa2101909

DO - 10.1056/NEJMoa2101909

M3 - Journal article

C2 - 34459570

SN - 0028-4793

VL - 385

SP - 2544

EP - 2553

JO - New England Journal of Medicine

JF - New England Journal of Medicine

IS - 27

ER -

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

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