No benefit of immediate coronary angiography after out-of-hospital cardiac arrest without ST-elevation

Coronary angiography after out-of-hospital cardiac arrest without ST-elevation (Tomahawk)

News - Aug. 29, 2021

Presented at the ESC congress 2021 by: Steffen Desch, MD Leipzig, Germany

Introduction and methods

The prognosis after out-of-hospital cardiac arrest is extremely poor with a survival rate of <10%. The most frequent underlying cause of out-of-hospital cardiac arrest is acute myocardial infarction (MI). Immediate angiography may improve treatment and subsequent prognosis in these patients.

The pro arguments for immediate angiography include possible prevention of large MI or injury, hemodynamic deterioration, future event such as, HF, hospitalizations and arrythmias. These arguments are valid in the presence of a treatable coronary lesion. The con arguments include risk of the procedure and the delay in diagnosis and treatment for etiologies other than MI.

The TOMAHAWK is a randomized trial of the timing of invasive coronary angiography after out-of-hospital cardiac arrest without ST-elevation on the ECG. 554 Patients after resuscitated out-of-hospital cardiac arrest of possible cardiac origin without ST-segment elevation were randomized in 1:1 ratio to immediate or delayed/selective coronary angiography at 31 sites in Germany and Denmark. Primary endpoint was mortality at 30 days.

Main results

  • There was no difference in the primary end point at 30 days between the immediate angiography group and the delayed/selective angiography group (HR 1.28, 95%CI: 1.00-1.63, P=0.058).


The TOMAHAWK trial showed no benefit on 30-day mortality of immediate routine coronary angiography in patients with resuscitated out-of-hospital cardiac arrest without ST-elevation.

Desch said: ‘For clinical practice, this means you can take your time and first evaluate the clinical course in the ICU. If still indicated, coronary angiography can be performed at a later time point in the following days.”

  • Our reporting is based on the information provided at the ESC Congress -

The results of TOMAHAWK were simultaneously presented in N Engl J Med.

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