https://doi.org/10.1007/s00392-025-02737-x
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: