Written by Samuel Rouleau
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In this subgroup analysis of the TOMAHAWK trial, researchers found no EKG results (excluding STEMI) that predicted the presence of coronary artery lesions in patients with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA).
No STEMI? Don’t rush for PCI!
Patients who suffer an OHCA and have STEMI (and maybe STEMI equivalents) on EKG after ROSC should undergo percutaneous coronary intervention (PCI) immediately. This pre-planned subgroup analysis of the TOMAHAWK trial sought to determine EKG findings predictive of coronary lesions in patients with ROSC after OHCA and no STEMI on post-ROSC EKG.
Out of 412 patients without STEMI on post-ROSC EKG, 163 (40%) had a coronary lesion. They were mostly male (71.4%) with a median age of 68; most had cardiac risk factors, such as hypertension (67.4%) and known CAD (46.7%). There were no statistically significant EKG differences between those with coronary artery lesions and those without. No EKG findings independently predicted the presence of a coronary artery lesion on univariate analysis. Notably, of the 160 patients with coronary artery lesions, 126 had sinus rhythm on their EKG, and 114 had no axis deviation. T-wave inversions, ST segment depressions, and ST segment depressions in 2 or more contiguous leads did not predict presence of coronary lesion. However, the incidence of ventricular tachycardia was exceedingly low (2 without coronary lesion group and 1 with coronary lesion group).
How will this change my practice?
This study reinforces what we are all currently doing:
- STEMI on post-ROSC EKG → PCI
- No STEMI on post-ROSC EKG → no emergent PCI
- OMI pattern → call cardiology
However, this subgroup analysis had a paucity of ventricular dysrhythmias, and if I had a post-ROSC patient with a high burden of ventricular dysrhythmias, I would call cardiology to discuss cardiac catheterization.
Source
Association of Electrocardiographic Patterns After Successfully Resuscitated Out-of-Hospital Cardiac Arrest With Significant Coronary Lesions and Mortality-A Predefined Angiography After Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation (TOMAHAWK) Trial. Crit Care Med. 2025 Feb 24. doi: 10.1097/CCM.0000000000006619. Epub ahead of print. PMID: 39992171
Was this also the study that indicated to wait 8 to 10 (maybe 12) minutes post ROSC to get an accurate ECG? Due to post ROSC ECG findings that show ST elevation that likely resolve as part of the ACLS measures.