Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial

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; Jesper Kjærgaard; 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; Denise Olbrich; Frank Sandig; Inke R König; Sabine Brett; Maren Vens; Kathrin Klinge; Holger Thiele; TOMAHAWK Investigators

doi:10.1001/jamacardio.2023.2264

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial

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, Jesper Kjærgaard, 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, Denise Olbrich, Frank Sandig, Inke R König, Sabine Brett, Maren Vens, Kathrin Klinge, Holger Thiele, TOMAHAWK Investigators

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10 Citationer (Scopus)

Abstract

IMPORTANCE: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear.

OBJECTIVE: To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up.

DESIGN, SETTING, AND PARTICIPANTS: The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death.

INTERVENTIONS: Early vs delayed or selective coronary angiography and revascularization if indicated.

MAIN OUTCOMES AND MEASURES: Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year.

RESULTS: A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups.

CONCLUSIONS AND RELEVANCE: This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02750462.

Originalsprog	Engelsk
Tidsskrift	JAMA Cardiology
Vol/bind	8
Udgave nummer	9
Sider (fra-til)	827-834
Antal sider	8
ISSN	2380-6583
DOI	https://doi.org/10.1001/jamacardio.2023.2264
Status	Udgivet - 1 sep. 2023

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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., 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, 8(9), 827-834. https://doi.org/10.1001/jamacardio.2023.2264

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 , Kjærgaard, J, 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, S, Olbrich, D, Sandig, F, König, IR, Brett, S, Vens, M, Klinge, K, Thiele, H & 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, bind 8, nr. 9, s. 827-834. https://doi.org/10.1001/jamacardio.2023.2264

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title = "Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial",

abstract = "IMPORTANCE: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear.OBJECTIVE: To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up.DESIGN, SETTING, AND PARTICIPANTS: The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death.INTERVENTIONS: Early vs delayed or selective coronary angiography and revascularization if indicated.MAIN OUTCOMES AND MEASURES: Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year.RESULTS: A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups.CONCLUSIONS AND RELEVANCE: This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02750462.",

keywords = "Aged, Coronary Angiography/adverse effects, Female, Heart Failure/complications, Hospitalization, Humans, Male, Middle Aged, Myocardial Infarction/complications, Out-of-Hospital Cardiac Arrest/diagnostic imaging",

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 Jesper Kj{\ae}rgaard 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}, 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}",

year = "2023",

month = sep,

day = "1",

doi = "10.1001/jamacardio.2023.2264",

language = "English",

volume = "8",

pages = "827--834",

journal = "JAMA Cardiology",

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TY - JOUR

T1 - Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation

T2 - One-Year Outcomes of a Randomized Clinical Trial

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 - Kjærgaard, Jesper

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, 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 - 2023/9/1

Y1 - 2023/9/1

N2 - IMPORTANCE: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear.OBJECTIVE: To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up.DESIGN, SETTING, AND PARTICIPANTS: The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death.INTERVENTIONS: Early vs delayed or selective coronary angiography and revascularization if indicated.MAIN OUTCOMES AND MEASURES: Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year.RESULTS: A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups.CONCLUSIONS AND RELEVANCE: This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02750462.

AB - IMPORTANCE: Myocardial infarction is a frequent cause of out-of-hospital cardiac arrest (OHCA). The long-term effect of early coronary angiography on patients with OHCA with possible coronary trigger but no ST-segment elevation remains unclear.OBJECTIVE: To compare the clinical outcomes of early unselective angiography with the clinical outcomes of a delayed or selective approach for successfully resuscitated patients with OHCA of presumed cardiac origin without ST-segment elevation at 1-year follow-up.DESIGN, SETTING, AND PARTICIPANTS: The TOMAHAWK trial was a multicenter, international (Germany and Denmark), investigator-initiated, open-label, randomized clinical trial enrolling 554 patients between November 23, 2016, to September 20, 2019. Patients with stable return of spontaneous circulation after OHCA of presumed cardiac origin but without ST-segment elevation on the postresuscitation electrocardiogram were eligible for inclusion. A total of 554 patients were randomized to either immediate coronary angiography after hospital admission or an initial intensive care assessment with delayed or selective angiography after a minimum of 24 hours. All 554 patients were included in survival analyses during the follow-up period of 1 year. Secondary clinical outcomes were assessed only for participants alive at 1 year to account for the competing risk of death.INTERVENTIONS: Early vs delayed or selective coronary angiography and revascularization if indicated.MAIN OUTCOMES AND MEASURES: Evaluations in this secondary analysis included all-cause mortality after 1 year, as well as severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure in survivors at 1 year.RESULTS: A total of 281 patients were randomized to the immediate angiography group and 273 to the delayed or selective group, with a median age of 70 years (IQR, 60-78 years). A total of 369 of 530 patients (69.6%) were male, and 268 of 483 patients (55.5%) had a shockable arrest rhythm. At 1 year, all-cause mortality was 60.8% (161 of 265) in the immediate angiography group and 54.3% (144 of 265) in the delayed or selective angiography group without significant difference between the treatment strategies, trending toward an increase in mortality with immediate angiography (hazard ratio, 1.25; 95% CI, 0.99-1.57; P = .05). For patients surviving until 1 year, the rates of severe neurologic deficit, myocardial infarction, and rehospitalization for congestive heart failure were similar between the groups.CONCLUSIONS AND RELEVANCE: This study found that a strategy of immediate coronary angiography does not provide clinical benefit compared with a delayed or selective invasive approach for patients 1 year after resuscitated OHCA of presumed coronary cause and without ST-segment elevation.TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02750462.

KW - Aged

KW - Coronary Angiography/adverse effects

KW - Female

KW - Heart Failure/complications

KW - Hospitalization

KW - Humans

KW - Male

KW - Middle Aged

KW - Myocardial Infarction/complications

KW - Out-of-Hospital Cardiac Arrest/diagnostic imaging

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U2 - 10.1001/jamacardio.2023.2264

DO - 10.1001/jamacardio.2023.2264

M3 - Journal article

C2 - 37556123

SN - 2380-6583

VL - 8

SP - 827

EP - 834

JO - JAMA Cardiology

JF - JAMA Cardiology

IS - 9

ER -

Coronary Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: One-Year Outcomes of a Randomized Clinical Trial

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