ESC 2021: TOMAHAWK trial does not support early coronary angiography in cardiac arrest without ST elevation

Steffen Desch

Early coronary angiography in out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation is not superior to a delayed/selective approach, according to new late-breaking research presented at the European Society of Cardiology’s 2021 congress (ESC 2021, 27–30 August, virtual).

The randomised open-label TOMAHAWK trial, the findings of which were also published in the New England Journal of Medicine, examined whether immediate coronary angiography for treating or ruling out acute coronary events in OHCA survivors without ST-segment elevation is beneficial for all-cause mortality at 30 days, compared with initial intensive care unit (ICU) assessment and delayed/selective angiography.

Principal investigator, Steffen Desch of the Heart Centre Leipzig, Germany, said: “TOMAHAWK was the second and largest randomised trial addressing the question of early coronary angiography in OHCA patients without ST-segment elevation. Like the COACT trial we found that early angiography was not superior to a delayed/selective approach. COACT was restricted to patients with shockable rhythm and TOMAHAWK extends the findings to patients with non-shockable rhythm.

“In TOMAHAWK, the higher rate of death or severe neurological deficit in the immediate angiography group is only hypothesis-generating. However, the results of the trial suggest that patients without a significant coronary lesion as the trigger of cardiac arrest do not benefit from an invasive approach and might even be harmed.”

The trial enrolled patients aged 30 years or older with successful resuscitation after OHCA, possible cardiac cause of arrest and absence of ST-segment elevation on post-resuscitation ECG. Patients with shockable and non-shockable rhythms were included.

A total of 554 patients were randomised at hospital admission in a 1:1 fashion to immediate coronary angiography or initial ICU assessment with delayed angiography if indicated. The primary endpoint was all-cause mortality at 30 days.

The primary endpoint occurred in 143 patients (54.0%) assigned to immediate coronary angiography and 122 patients (46%) in the delayed/selective angiography group (hazard ratio 1.28; 95% confidence interval [CI] 1.00–1.63; log-rank p=0.058). No differences in the primary endpoint were observed in pre-specified subgroups, including those with shockable versus non-shockable rhythm.

The composite secondary endpoint of all-cause death or severe neurological deficit at 30 days occurred more frequently in the immediate angiography group (relative risk 1.16; 95% CI 1.002– 1.34). Other secondary endpoints such as length of ICU stay, peak troponin release, myocardial infarction or rehospitalisation for congestive heart failure did not differ between groups. There were no differences between groups in safety endpoints including moderate or severe bleeding, stroke and acute renal failure requiring renal replacement therapy.


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