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

doi:10.1056/NEJMoa2101909

Randomized Controlled Trial

. 2021 Dec 30;385(27):2544-2553.

doi: 10.1056/NEJMoa2101909. Epub 2021 Aug 29.

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

Steffen Desch¹, Anne Freund¹, Ibrahim Akin¹, Michael Behnes¹, Michael R Preusch¹, Thomas A Zelniker¹, Carsten Skurk¹, Ulf Landmesser¹, Tobias Graf¹, Ingo Eitel¹, Georg Fuernau¹, Hendrik Haake¹, Peter Nordbeck¹, Fabian Hammer¹, Stephan B Felix¹, Christian Hassager¹, Thomas Engstrøm¹, Stephan Fichtlscherer¹, Jakob Ledwoch¹, Karsten Lenk¹, Michael Joner¹, Stephan Steiner¹, Christoph Liebetrau¹, Ingo Voigt¹, Uwe Zeymer¹, Michael Brand¹, Roland Schmitz¹, Jan Horstkotte¹, Claudius Jacobshagen¹, Janine Pöss¹, Mohamed Abdel-Wahab¹, Philipp Lurz¹, Alexander Jobs¹, Suzanne de Waha-Thiele¹, Denise Olbrich¹, Frank Sandig¹, Inke R König¹, Sabine Brett¹, Maren Vens¹, Kathrin Klinge¹, Holger Thiele¹; TOMAHAWK Investigators

Collaborators, Affiliations

Collaborators

TOMAHAWK Investigators:
Steffen Desch, Anne Freund, Holger Thiele, Kathrin Klinge, Sabine Brett, Inke R König, Maren Vens, Frank Sandig, Ulrich Tebbe, Michael Oeff, Karl Georg Häusler, Guido Michels, Karl Werdan, Joachim Gerß, Ibrahim Akin, Michael Behnes, Uzair Ansari, Michael R Preusch, Jan Stiepak, Tobias Graf, Karolin Schmoll, Georg Fuernau, Thomas Stiermaier, Ingo Eitel, Suzanne de Waha-Thiele, Ulf Landmesser, Carsten Skurk, Thomas Wurster, Wulf Knie, Hendrik Haake, Jürgen Vom Dahl, Christian Kotzlowski, Peter Nordbeck, Octavian Maniuc, Maria Moritz, Fabian Hammer, Stephan B Felix, Peter Abel, Daniel Beug, Christian Hassager, Jesper Kjaergaard, Thomas Engstrøm, Stephan Fichtlscherer, Mariuca Vasa-Nicotera, Stephan Heyl, Jakob Ledwoch, Christian Kupatt, Petra Hoppmann, Christian Bradaric, Karsten Lenk, Ulrich Laufs, Daniel Lavall, Michael Joner, Patrick Mayr, Anna-Lena Lahmann, Janine Pöss, Mohamed Abdel-Wahab, Philipp Lurz, Alexander Jobs, Stephan Steiner, Stefanie Weigel, Christoph Liebetrau, Maren Weferling, Catharina Hamm, Ingo Voigt, Thomas Schmitz, Uwe Zeymer, Ralph Winkler, Michael Brand, Hans-Joachim Trappe, Roland Schmitz, Christian Valina, Simon Schöchlin, Christoph Garlichs, Jan Horstkotte, Claudius Jacobshagen, Tim Seidler, Gerd Hasenfuß, Sylvia Otto, Sven Möbius-Winkler, P Christian Schulze, Tommaso Gori, Stephan Kische, Peter Grewe, Klaus Pels, Stefan Sack, Harald Mudra, Niels Menck, Norman Klöppner, Stefan Löser, Philipp Lauten, Axel Linke, Norman Mangner, Felix Woitek, Derk Frank, Matthias Lutz, Norbert Frey, Tobias Geisler, Michal Droppa, Marc-Alexander Ohlow

Affiliation

¹ From Heart Center Leipzig at the University of Leipzig, Departments of Internal Medicine-Cardiology (S.D., A.F., J.P., M.A.-W., P.L., A.J., H.T.) and Cardiac Surgery (S.W.-T.), Leipzig Heart Institute (S.D., A.F., A.J., H.T.), and University Clinic Leipzig (K.L.), Leipzig, University Heart Center Lübeck (S.D., T.G., I.E., G.F., A.J.) and the Center for Clinical Trials (D.O., S.B., K.K.) and the Institute for Medical Biometry and Statistics (F.S., I.R.K., M.V.), University of Lübeck, Lübeck, the German Center for Cardiovascular Research (S.D., A.F., I.A., M. Behnes, M.R.P., T.A.Z., C.S., U.L., T.G., I.E., G.F., F.H., S.B.F., S.F., J.L., M.J., C.L., C.J., A.J., D.O., F.S., I.R.K., S.B., M.V., K.K.) and University Clinic Charité, Campus Benjamin Franklin (C.S., U.L.), Berlin, University Clinic Mannheim, Mannheim (I.A., M. Behnes), the Department of Cardiology, Angiology, and Pneumology, University Hospital of Heidelberg, Heidelberg (M.R.P., T.A.Z.), Kliniken Maria Hilf, Mönchengladbach (H.H.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Greifswald, Greifswald (F.H., S.B.F.), University Clinic Frankfurt, Frankfurt (S.F.), Rechts der Isar Hospital, Technical University (J.L.), and the Department of Cardiology, German Heart Center (M.J.), Munich, the Department of Cardiology, Pneumology and Intensive Care, St. Vincenz Hospital, Limburg (S.S.), Kerckhoff Clinic, Bad Nauheim (C.L.), the Departments of Acute and Emergency Medicine and of Cardiology and Angiology, Elisabeth Hospital Essen, Essen (I.V.), Klinikum Ludwigshafen, Ludwigshafen (U.Z.), University Clinic Marien Hospital Herne, Klinikum der Ruhr-Universität Bochum, Herne (M. Brand), the University Heart Center, Bad Krozingen (R.S.), Diakonissenkrankenhaus Flensburg, Flensburg (J.H.), University Medicine Göttingen, Göttingen (C.J.), and Vincentius-Diakonissen Hospital, Karlsruhe (C.J.) - all in Germany; the Division of Cardiology, Medical University of Vienna, Vienna (T.A.Z.); and the Department of Cardiology, Rigshospitalet, and the Department of Clinical Medicine, University of Copenhagen - both in Copenhagen (C.H., T.E.).

PMID: 34459570
DOI: 10.1056/NEJMoa2101909

Free article

Randomized Controlled Trial

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

Steffen Desch et al. N Engl J Med. 2021.

Free article

. 2021 Dec 30;385(27):2544-2553.

doi: 10.1056/NEJMoa2101909. Epub 2021 Aug 29.

Authors

Collaborators

TOMAHAWK Investigators:
Steffen Desch, Anne Freund, Holger Thiele, Kathrin Klinge, Sabine Brett, Inke R König, Maren Vens, Frank Sandig, Ulrich Tebbe, Michael Oeff, Karl Georg Häusler, Guido Michels, Karl Werdan, Joachim Gerß, Ibrahim Akin, Michael Behnes, Uzair Ansari, Michael R Preusch, Jan Stiepak, Tobias Graf, Karolin Schmoll, Georg Fuernau, Thomas Stiermaier, Ingo Eitel, Suzanne de Waha-Thiele, Ulf Landmesser, Carsten Skurk, Thomas Wurster, Wulf Knie, Hendrik Haake, Jürgen Vom Dahl, Christian Kotzlowski, Peter Nordbeck, Octavian Maniuc, Maria Moritz, Fabian Hammer, Stephan B Felix, Peter Abel, Daniel Beug, Christian Hassager, Jesper Kjaergaard, Thomas Engstrøm, Stephan Fichtlscherer, Mariuca Vasa-Nicotera, Stephan Heyl, Jakob Ledwoch, Christian Kupatt, Petra Hoppmann, Christian Bradaric, Karsten Lenk, Ulrich Laufs, Daniel Lavall, Michael Joner, Patrick Mayr, Anna-Lena Lahmann, Janine Pöss, Mohamed Abdel-Wahab, Philipp Lurz, Alexander Jobs, Stephan Steiner, Stefanie Weigel, Christoph Liebetrau, Maren Weferling, Catharina Hamm, Ingo Voigt, Thomas Schmitz, Uwe Zeymer, Ralph Winkler, Michael Brand, Hans-Joachim Trappe, Roland Schmitz, Christian Valina, Simon Schöchlin, Christoph Garlichs, Jan Horstkotte, Claudius Jacobshagen, Tim Seidler, Gerd Hasenfuß, Sylvia Otto, Sven Möbius-Winkler, P Christian Schulze, Tommaso Gori, Stephan Kische, Peter Grewe, Klaus Pels, Stefan Sack, Harald Mudra, Niels Menck, Norman Klöppner, Stefan Löser, Philipp Lauten, Axel Linke, Norman Mangner, Felix Woitek, Derk Frank, Matthias Lutz, Norbert Frey, Tobias Geisler, Michal Droppa, Marc-Alexander Ohlow

Affiliation

¹ From Heart Center Leipzig at the University of Leipzig, Departments of Internal Medicine-Cardiology (S.D., A.F., J.P., M.A.-W., P.L., A.J., H.T.) and Cardiac Surgery (S.W.-T.), Leipzig Heart Institute (S.D., A.F., A.J., H.T.), and University Clinic Leipzig (K.L.), Leipzig, University Heart Center Lübeck (S.D., T.G., I.E., G.F., A.J.) and the Center for Clinical Trials (D.O., S.B., K.K.) and the Institute for Medical Biometry and Statistics (F.S., I.R.K., M.V.), University of Lübeck, Lübeck, the German Center for Cardiovascular Research (S.D., A.F., I.A., M. Behnes, M.R.P., T.A.Z., C.S., U.L., T.G., I.E., G.F., F.H., S.B.F., S.F., J.L., M.J., C.L., C.J., A.J., D.O., F.S., I.R.K., S.B., M.V., K.K.) and University Clinic Charité, Campus Benjamin Franklin (C.S., U.L.), Berlin, University Clinic Mannheim, Mannheim (I.A., M. Behnes), the Department of Cardiology, Angiology, and Pneumology, University Hospital of Heidelberg, Heidelberg (M.R.P., T.A.Z.), Kliniken Maria Hilf, Mönchengladbach (H.H.), University Clinic Würzburg, Würzburg (P.N.), University Clinic Greifswald, Greifswald (F.H., S.B.F.), University Clinic Frankfurt, Frankfurt (S.F.), Rechts der Isar Hospital, Technical University (J.L.), and the Department of Cardiology, German Heart Center (M.J.), Munich, the Department of Cardiology, Pneumology and Intensive Care, St. Vincenz Hospital, Limburg (S.S.), Kerckhoff Clinic, Bad Nauheim (C.L.), the Departments of Acute and Emergency Medicine and of Cardiology and Angiology, Elisabeth Hospital Essen, Essen (I.V.), Klinikum Ludwigshafen, Ludwigshafen (U.Z.), University Clinic Marien Hospital Herne, Klinikum der Ruhr-Universität Bochum, Herne (M. Brand), the University Heart Center, Bad Krozingen (R.S.), Diakonissenkrankenhaus Flensburg, Flensburg (J.H.), University Medicine Göttingen, Göttingen (C.J.), and Vincentius-Diakonissen Hospital, Karlsruhe (C.J.) - all in Germany; the Division of Cardiology, Medical University of Vienna, Vienna (T.A.Z.); and the Department of Cardiology, Rigshospitalet, and the Department of Clinical Medicine, University of Copenhagen - both in Copenhagen (C.H., T.E.).

PMID: 34459570
DOI: 10.1056/NEJMoa2101909

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.).

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Comment in

Delayed angiography for non-ST-elevation OHCA.
Huynh K. Huynh K. Nat Rev Cardiol. 2021 Nov;18(11):738. doi: 10.1038/s41569-021-00623-3. Nat Rev Cardiol. 2021. PMID: 34508232 No abstract available.

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

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

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