Effect of Timing of Coronary Angiography on Mortality After Out-of-hospital Cardiac Arrest in Elderly Patients - A Substudy of the TOMAHAWK Trial

T. Thevathasan (Berlin)¹, S. Pugachova (Berlin)², J. Pöss (Leipzig)³, U. Landmesser (Berlin)⁴, C. Skurk (Berlin)¹, H.-J. Feistritzer (Leipzig)³, A. Jobs (Leipzig)³, S. de Waha (Leipzig)⁵, H. Thiele (Leipzig)³, A. Freund (Leipzig)³, S. Desch (Leipzig)^3
1Charité - Universitätsmedizin Berlin CC 11: Med. Klinik für Kardiologie Berlin, Deutschland; ²Vivantes Klinikum Spandau Klinik für Innere Medizin - Kardiologie Berlin, Deutschland; ³Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ⁴Deutsches Herzzentrum der Charite (DHZC) Klinik für Kardiologie, Angiologie und Intensivmedizin Berlin, Deutschland; ⁵Herzzentrum Leipzig - Universität Leipzig Universitätsklinik für Herzchirurgie Leipzig, Deutschland

Background: 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 versus delayed/selective coronary angiography in elderly versus younger OHCA survivors.
Methods: A total of 529 patients with successfully resuscitated OHCA of presumed cardiac origin without ST-segment elevations on post-resuscitation electrocardiograms were analyzed. Patients were randomized to immediate or delayed/selective coronary angiography (≥24 hours following OHCA). Patients were stratified by age: elderly patients defined as >75 years versus younger patients as ≤75 years. The primary endpoint was 30-day mortality. Multivariable Cox regression models, Kaplan-Meier survival estimates and age-dependent spline analyses were applied.
Results: Elderly patients exhibited a greater burden of cardiovascular comorbidities, had higher 30-day mortality (69% vs. 43%, p<0.001) and higher rates of death or severe hypoxic brain injury (75% vs. 51%, p<0.001) compared to younger individuals. In unadjusted analyses, delayed/selective coronary angiography was associated with lower mortality in elderly patients (Hazard ratio 0.69 [95% confidence interval, 0.49-0.99], p=0.046; Figure 1). Spline analyses revealed a U-shaped age-mortality relationship with immediate coronary angiography, showing increased risk in both very young and very old patients (Figure 2).
Conclusions: In elderly OHCA survivors without ST-segment elevations, routine immediate coronary angiography may increase mortality risk. These findings emphasize the need for individualized decision-making and careful patient selection, with post-resuscitation strategies that balance therapeutic benefit against procedural risk especially in this vulnerable population.

Figure 1:


Figure 2: