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Immediate coronary angiography does not alter 30-day mortality in OHCA survivors without ST elevationTiming of heart scans does not change survival odds for older cardiac arrest survivors

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Key Takeaway
Consider that immediate coronary angiography may not improve survival in OHCA patients without ST elevation, regardless of age.

This randomized controlled trial enrolled 529 patients with successfully resuscitated out-of-hospital cardiac arrest of presumed cardiac origin without ST-segment elevations. Patients were stratified by age into elderly (>75 years) and younger (≤75 years) groups and randomized to immediate coronary angiography or delayed/selective angiography after 24 hours.

The primary outcome was 30-day mortality. For elderly patients, the hazard ratio was 0.96 (95% CI 0.59-1.56, P=0.88), with an absolute mortality rate of 69%. For younger patients, the hazard ratio was 0.88 (95% CI 0.56-1.38, P=0.57), with an absolute mortality rate of 43%. The difference between strategies was not statistically significant in either age group.

A secondary outcome was death or severe neurologic deficit. This occurred in 75% of elderly patients versus 51% of younger patients (P<0.001). Safety data, including adverse events and discontinuations, were not reported.

Key limitations include the lack of reported safety data and the absence of details on study setting. The practice relevance is that routine immediate coronary angiography does not appear to modify mortality risk in OHCA survivors without ST elevation, and results do not support differential treatment by age.

Imagine a loved one waking up after a scary event outside the hospital. The team worked hard to bring them back to life. Now they face a hard choice about next steps. Doctors often wonder if a quick scan helps.

Many people survive cardiac arrest. But not everyone gets better. Some face long recovery while others do not. This is true for older adults who often have other health issues.

Doctors usually scan hearts quickly to find blockages. They think this saves lives. But new data questions this habit for older patients.

But here is the twist. The scan timing did not change survival chances. This holds true for both young and old groups.

The heart works like a complex factory. Blood must flow freely to power every room. Blockages stop the flow and cause damage. Doctors look for these blockages to fix the problem.

However, not all heart problems show up as obvious blockages. Some issues involve electrical signals or other causes. A scan only sees the plumbing. It misses other factory problems.

The TOMAHAWK trial looked at 529 patients. Half got scans right away. The other half waited at least 24 hours. Researchers tracked who lived and who did not within 30 days.

They split the group by age. Older patients were over 75 years old. Younger patients were 75 or under. Older patients had more health problems before the event.

Older patients faced higher death rates overall. Sixty nine percent died within 30 days. Forty three percent of younger patients died. This gap is common in medicine.

Yet the scan timing made no difference. Age did not change the outcome either. The risk of death stayed the same regardless of the scan schedule.

This does not mean this treatment is available yet.

Experts say this fits the bigger picture. Many patients have multiple health issues. These issues often drive poor outcomes more than one blockage.

For patients without ST elevation signs, the scan timing matters less. These patients likely do not have a classic heart attack. Their needs differ from those with clear heart attack signs.

What does this mean for you? Talk to your doctor about the plan. Ask why a scan is needed now. Consider your specific health history and risks.

The study has limits. It focused on patients without ST elevation signs. Results may differ for those with clear heart attack signs. Also, the study came from one region.

More research is coming. Trials will test other treatments and timings. Science takes time to prove new ideas. Patience helps us find the best care.

Study Details

Study typeRct
Sample sizen = 529
EvidenceLevel 2
Follow-up900.0 mo
PublishedApr 2026
View Original Abstract ↓
AIMS: The optimal timing of coronary angiography in elderly patients after out-of-hospital cardiac arrest (OHCA) without ST-segment elevations after successful resuscitation remains uncertain. This substudy of the randomized TOMAHAWK trial investigated the prognostic impact of immediate vs. delayed/selective coronary angiography in elderly vs. younger OHCA survivors. METHODS AND RESULTS: A total of 529 patients with successfully resuscitated OHCA of presumed cardiac origin without ST-segment elevations on post-resuscitation electrocardiograms were analysed. Patients had been randomized to immediate or delayed/selective coronary angiography after 24 h at the earliest. Patients were stratified by age: elderly patients defined as >75 years vs. younger patients as ≤75 years. The primary endpoint was 30-day mortality. Multivariable Cox regression models were applied. Elderly patients exhibited a greater burden of cardiovascular comorbidities, had higher 30-day mortality (69% vs. 43%, P < 0.001), and had higher rates of death or severe neurologic deficit (75% vs. 51%, P < 0.001) compared to younger individuals. In adjusted analyses, the timing of coronary angiography was not significantly associated with mortality in either elderly patients (HR 0.96, 95% CI, 0.59-1.56, P = 0.88) or younger patients (HR 0.88, 95% CI, 0.56-1.38, P = 0.57), with no evidence of effect modification by age (P for interaction = 0.758). CONCLUSION: Routine immediate coronary angiography does not appear to modify mortality risk in both elderly and younger OHCA survivors without ST-segment elevations. The results do not support differential treatment strategies across age groups.
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