TOMAHAWK

Population

• Patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin and no ST-segment elevation on postresuscitation electrocardiography.

Intervention

Immediate coronary angiography.

Comparator

Initial intensive care assessment with delayed or selective angiography.

Key results

• Thirty-day death: 143 of 265 (54.0%) with immediate angiography vs 122 of 265 (46.0%) with delayed angiography; HR 1.28 (95% CI 1.00-1.63; p=0.06).
• The composite of death or severe neurologic deficit was 164 of 255 (64.3%) with immediate angiography vs 138 of 248 (55.6%) with delayed angiography (RR 1.16; 95% CI 1.00-1.34).
• Peak troponin release and the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups.

Harms

• The incidence of moderate or severe bleeding, stroke, and renal-replacement therapy was similar in the two groups.
• The composite of death or severe neurologic deficit was 64.3% with immediate angiography vs 55.6% with delayed angiography (RR 1.16; 95% CI 1.00-1.34).

Practice impact

• After resuscitated out-of-hospital cardiac arrest without ST-segment elevation, start intensive care assessment first and use delayed or selective angiography.

Applicability

• Most applicable to successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin without ST-segment elevation on the postresuscitation ECG.

Limitations

• The 30-day mortality difference did not reach the stated significance threshold.
• Results do not apply to patients with ST-segment elevation.
• The comparator allowed delayed or selective angiography rather than no angiography.

Common misinterpretations

• Immediate angiography is not required after out-of-hospital cardiac arrest without ST-segment elevation.
• Similar bleeding, stroke, and renal-replacement rates do not make the strategies equivalent for survival.