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

TOMAHAWK Investigators

202 Citations (Scopus)


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 number, NCT02750462.).

Original languageEnglish
JournalNew England Journal of Medicine
Issue number27
Pages (from-to)2544-2553
Number of pages10
Publication statusPublished - 30 Dec 2021


  • 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


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