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.).
N Engl J Med. 2021 Dec 30;385(27):2544-2553. doi: 10.1056/NEJMoa2101909. Epub 2021 Aug 29.
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.
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.
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.
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.).
心肌梗死是院外心脏骤停的常见原因。然而，对于没有心电图 ST 段抬高证据的复苏后患者，早期进行冠状动脉造影和血运重建的益处尚不清楚。
在这项多中心试验中，我们将 554 例经复苏成功的、可能由冠状动脉引起的院外心脏骤停患者随机分为两组：立即行冠状动脉造影（即刻造影组）或初始强化监护评估后行延迟或选择性冠状动脉造影（延迟造影组）。所有患者在复苏后心电图上均无 ST 段抬高的证据。主要终点是 30 天时的任何原因导致的死亡。次要终点包括 30 天时的任何原因导致的死亡或严重神经功能缺损的复合终点。
共有 554 例患者中的 530 例（95.7%）纳入主要分析。在 30 天时，即刻造影组 265 例患者中有 143 例（54.0%）死亡，延迟造影组 265 例患者中有 122 例（46.0%）死亡（风险比，1.28；95%置信区间[CI]，1.00 至 1.63；P=0.06）。即刻造影组（255 例患者中的 164 例[64.3%]）中死亡或严重神经功能缺损的复合终点发生率高于延迟造影组（248 例患者中的 138 例[55.6%]），相对风险为 1.16（95%CI，1.00 至 1.34）。两组间肌钙蛋白峰值释放率以及中重度出血、卒中和肾脏替代治疗的发生率相似。
在无 ST 段抬高的院外心脏骤停复苏患者中，与延迟或选择性策略相比，即刻行冠状动脉造影的策略并不能降低 30 天时的任何原因死亡风险。（由德国心血管研究中心资助；TOMAHAWK 临床试验.gov 编号，NCT02750462。）
