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Rushing Angiography for OHCA Patients without ST-Segment Elevation Largely Unbeneficial
TOMAHAWK investigators stress importance of selective and thorough process for angio for better outcomes
Performing coronary angiography immediately for out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation does not better survival outcomes, findings from the TOMAHAWK trial showed.
Steffen Desch, MD (Heart Centre Leipzig, Germany), the principal investigator of TOMAHAWK, presented late-breaking trial findings on the timing of invasive coronary angiography at the European Society of Cardiology (ESC) Congress 2021, stressing that later does not always mean worse.
“Like the COACT trial, we found that early angiography was not superior to a delayed and selective approach,” Desch said. “Although COACT restricted enrollment to patients with shockable rhythm, findings from this second and largest randomized trial extends [COACT] findings to those with non-shockable rhythm.”
Results were published simultaneously in the New England Journal of Medicine (NEJM)1.
COACT2 previously found that a broad, immediate angiography strategy was not superior to a delayed approach. However, the trial only included patients with shockable rhythm, thereby creating uncertainty for a large number of OHCA patients (60%) who do not present ST-segment elevation.
“Our findings imply you should take your time and evaluate the clinical course first and - if still indicated - perform coronary angiography in the following days,” Desch said.
Coronary angiography is used to scan for myocardial infarction (MI), a significant cause of out-of-hospital cardiac arrest that carries a near 65% mortality rate even after successful resuscitation and hospitalization.
Angiographies can help prevent myocardial injury, hemodynamic deterioration, heart failure, rehospitalization, and arrhythmias when the coronary lesion is treatable.
However, when the source of OHCA springs from untreatable coronary lesions, invasive angio may do more harm than good by raising risks of procedural complications of renal damage, reperfusion injury, stent thrombosis, bleeding, and cerebral damage.
Immediate cardiac cath is not necessary for the majority of patients.
Based on the COACT trial, ESC guidelines have already recommended delayed – not immediate – coronary angiography for successfully resuscitated, hemodynamically stable OHCA patients without ST-segment elevation. However, the benefits of an early invasive approach for OHCA with non-shockable rhythm remains poorly defined.
The investigator-initiated, randomized, international, multicenter, open-label TOMAHAWK study tested the potential benefits of an immediate coronary angiography for treating or ruling out acute coronary events.
Investigators randomly assigned 554 patients from 31 sites in Germany and Denmark who were successfully resuscitated after OHCA to either immediate (n=265) or delayed angiography (n=265).
Post-resuscitation ECG showed no patients had evidence of ST-segment elevation, and patients with shockable and non-shockable rhythm were both enrolled (median age 70; female 30%).
The primary endpoint was death from any cause at 30-days. Secondary endpoints were a composite of death from any cause or severe neurologic deficit at 30 days.
Results showed that mortality rates were 54% in the immediate-angio group and 46% in the delayed-angio group, indicating no significant difference between the two arms and shockable (55.5%) or non-shockable rhythm patients (HR 1.28, 95% CI, 1.00-1.63; P=0.06).
The immediate-angio group also had more composite rates of death or severe neurologic deficit than the delayed-angio group (64.3% vs. 55.6%, HR 1.16, 95% CI, 1.00-1.34).
Other values, such as peak troponin release, length of intensive care unit (ICU) stay, and MI incidence, proved similar between the two arms.
Safety endpoints of moderate or severe bleeding, stroke, and renal replacement therapy showed no significant difference.
Notably, the “delays” in proceeding to angio in the TOMAHAWK trial did not bar cardiac revascularization rates. Findings showed that revascularization rates between the immediate-angio and delayed-angio groups were similar and even higher in the delayed angio arm (immediate-angio 37.2% vs. delayed-angio 43.2%).
TOMAHAWK findings communicate an important message for OHCA: take the time for careful patient selection instead of rushing to cath.
In a video interview with TCTMD3, Desch speculated that the revascularization rate in the delayed angio arm was possibly higher because physicians were more selective and detailed in assessing the patient.
“The higher rate of death and severe neurological deficits in the immediate angio group remains only hypothesis-generating. However, results of the trial suggest that patients without significant coronary lesions as the trigger of cardiac arrest do not benefit from an invasive approach and may even be harmed,” he said.
“These results help us avoid unnecessary immediate cardiac catheterizations after OHCA and resolve the issues of ambiguity,, indicating that immediate cardiac cath is not necessary for the majority of patients.”
But how late is too late?
Findings from the TOMAHAWK trial are likely to change clinical practice - discussants at ESC 2021 and commentators said – helping clinicians buy more time for increased precision and thoroughness in clinical evaluations before rushing to angio.
“In my practice, this means I won’t be waking up at 3 a.m. to rush an angio anymore – I would take more time and be more selective,” Desch said to TCTMD, pointing out that the practice of rushed angio for most OHCA patients lacks clinical evidence.
However, he stressed that swift angio remains beneficial in certain patients and does not always mean more harm.
How much time is too much is also emerging as a critical question. For reference, results showed that the average time to angio in COACT was 5 days and 2 days in TOMAHAWK.
On this matter, Desch explained that the optimal time to angio is not straightforward; generally, results from COACT and TOMAHAWK point toward a shift for treatment based on the individual patient.
Commenting on study findings to SummitMD, Do-Yoon Kang (Asan Medical Center, Seoul, South Korea) said: “Fewer patients in the delayed angio arm had to undergo an angiography (95.5% vs. 62.2%) and had more radial access (28.0% vs. 40.4%). Patients in the delayed angiography arm also had a higher rate of PCI after being diagnosed with significant coronary disease (37.2% vs. 43.2%). Taken together, the results from TOMAHAWK communicate an important message: take time to carefully select OHCA patients instead of rushing to the cath lab for better outcomes.”
Edited by
Do-Yoon Kang, MD
Asan Medical Center, Korea (Republic of)
Written by
YoonJee Marian Chu, Medical Journalist
Read Biography
Performing coronary angiography immediately for out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation does not better survival outcomes, findings from the TOMAHAWK trial showed.
Steffen Desch, MD (Heart Centre Leipzig, Germany), the principal investigator of TOMAHAWK, presented late-breaking trial findings on the timing of invasive coronary angiography at the European Society of Cardiology (ESC) Congress 2021, stressing that later does not always mean worse.
“Like the COACT trial, we found that early angiography was not superior to a delayed and selective approach,” Desch said. “Although COACT restricted enrollment to patients with shockable rhythm, findings from this second and largest randomized trial extends [COACT] findings to those with non-shockable rhythm.”
Results were published simultaneously in the New England Journal of Medicine (NEJM)1.
COACT2 previously found that a broad, immediate angiography strategy was not superior to a delayed approach. However, the trial only included patients with shockable rhythm, thereby creating uncertainty for a large number of OHCA patients (60%) who do not present ST-segment elevation.
“Our findings imply you should take your time and evaluate the clinical course first and - if still indicated - perform coronary angiography in the following days,” Desch said.
Coronary angiography is used to scan for myocardial infarction (MI), a significant cause of out-of-hospital cardiac arrest that carries a near 65% mortality rate even after successful resuscitation and hospitalization.
Angiographies can help prevent myocardial injury, hemodynamic deterioration, heart failure, rehospitalization, and arrhythmias when the coronary lesion is treatable.
However, when the source of OHCA springs from untreatable coronary lesions, invasive angio may do more harm than good by raising risks of procedural complications of renal damage, reperfusion injury, stent thrombosis, bleeding, and cerebral damage.
Immediate cardiac cath is not necessary for the majority of patients.
Based on the COACT trial, ESC guidelines have already recommended delayed – not immediate – coronary angiography for successfully resuscitated, hemodynamically stable OHCA patients without ST-segment elevation. However, the benefits of an early invasive approach for OHCA with non-shockable rhythm remains poorly defined.
The investigator-initiated, randomized, international, multicenter, open-label TOMAHAWK study tested the potential benefits of an immediate coronary angiography for treating or ruling out acute coronary events.
Investigators randomly assigned 554 patients from 31 sites in Germany and Denmark who were successfully resuscitated after OHCA to either immediate (n=265) or delayed angiography (n=265).
Post-resuscitation ECG showed no patients had evidence of ST-segment elevation, and patients with shockable and non-shockable rhythm were both enrolled (median age 70; female 30%).
The primary endpoint was death from any cause at 30-days. Secondary endpoints were a composite of death from any cause or severe neurologic deficit at 30 days.
Results showed that mortality rates were 54% in the immediate-angio group and 46% in the delayed-angio group, indicating no significant difference between the two arms and shockable (55.5%) or non-shockable rhythm patients (HR 1.28, 95% CI, 1.00-1.63; P=0.06).
The immediate-angio group also had more composite rates of death or severe neurologic deficit than the delayed-angio group (64.3% vs. 55.6%, HR 1.16, 95% CI, 1.00-1.34).
Other values, such as peak troponin release, length of intensive care unit (ICU) stay, and MI incidence, proved similar between the two arms.
Safety endpoints of moderate or severe bleeding, stroke, and renal replacement therapy showed no significant difference.
Notably, the “delays” in proceeding to angio in the TOMAHAWK trial did not bar cardiac revascularization rates. Findings showed that revascularization rates between the immediate-angio and delayed-angio groups were similar and even higher in the delayed angio arm (immediate-angio 37.2% vs. delayed-angio 43.2%).
TOMAHAWK findings communicate an important message for OHCA: take the time for careful patient selection instead of rushing to cath.
In a video interview with TCTMD3, Desch speculated that the revascularization rate in the delayed angio arm was possibly higher because physicians were more selective and detailed in assessing the patient.
“The higher rate of death and severe neurological deficits in the immediate angio group remains only hypothesis-generating. However, results of the trial suggest that patients without significant coronary lesions as the trigger of cardiac arrest do not benefit from an invasive approach and may even be harmed,” he said.
“These results help us avoid unnecessary immediate cardiac catheterizations after OHCA and resolve the issues of ambiguity,, indicating that immediate cardiac cath is not necessary for the majority of patients.”
But how late is too late?
Findings from the TOMAHAWK trial are likely to change clinical practice - discussants at ESC 2021 and commentators said – helping clinicians buy more time for increased precision and thoroughness in clinical evaluations before rushing to angio.
“In my practice, this means I won’t be waking up at 3 a.m. to rush an angio anymore – I would take more time and be more selective,” Desch said to TCTMD, pointing out that the practice of rushed angio for most OHCA patients lacks clinical evidence.
However, he stressed that swift angio remains beneficial in certain patients and does not always mean more harm.
How much time is too much is also emerging as a critical question. For reference, results showed that the average time to angio in COACT was 5 days and 2 days in TOMAHAWK.
On this matter, Desch explained that the optimal time to angio is not straightforward; generally, results from COACT and TOMAHAWK point toward a shift for treatment based on the individual patient.
Commenting on study findings to SummitMD, Do-Yoon Kang (Asan Medical Center, Seoul, South Korea) said: “Fewer patients in the delayed angio arm had to undergo an angiography (95.5% vs. 62.2%) and had more radial access (28.0% vs. 40.4%). Patients in the delayed angiography arm also had a higher rate of PCI after being diagnosed with significant coronary disease (37.2% vs. 43.2%). Taken together, the results from TOMAHAWK communicate an important message: take time to carefully select OHCA patients instead of rushing to the cath lab for better outcomes.”
Edited by
Do-Yoon Kang, MD
Asan Medical Center, Korea (Republic of)
Written by
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