Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest
Introduction
In Western countries, cardiac arrest due to cardiovascular disease is the leading cause of death in adults with an incidence of up to 128 per 100 000 people [1], [2]. Thrombolytic therapy was reported to improve survival in patients with acute myocardial infarction (MI) and massive pulmonary embolism (PE) [3], [4]. In MI, in particular, early administration of thrombolytic agents may diminish the extent of damage to the heart muscle by reducing the duration of ischaemia and consequently improve the quality of outcome. The question arises why thrombolytic therapy is rarely considered in patients with cardiac arrest of cardiovascular aetiology [5]. Anticipated profound haemorrhage is a prime reason why little is reported about the efficacy of thrombolytic therapy during cardiopulmonary resuscitation in out-of-hospital cardiac arrest [5], [6], [7].
There is evidence that ischaemia/hypoxia triggers marked activation of blood coagulation and massive fibrin generation [8]. Endogenous thrombolysis may not be sufficient to counteract blood coagulation [9]. Formation of microthrombi impairs microcirculation and contributes to reperfusion disorders. Consequently, it determines the degree of derangement of vital organ function and outcome [10], [11], [12].
Our hypothesis was that successful recanalization of obstructed vessels following thrombolysis produces better results in patients resuscitated with cardiac arrest of non-traumatic aetiology. Irrespective of the benefit for patients with MI or PE, thrombolysis may improve the overall circulatory function in CPR. This study was designed to evaluate the impact of thrombolytic therapy on ROSC, hospitalization and outcome in patients with out-of-hospital resuscitation.
Section snippets
Study background
Innsbruck, a city in the alpine part of Austria, has a population of 129 800 (1998 census), 16.8% of whom are more than 65 years old. Another 20 000 people live in semi-rural areas in the close vicinity. During the entire period of data collection, the EMS was two-tiered. In emergency cases, the dispatcher immediately sent an ambulance with rescue personnel able to provide basic life support including chest compression and bag mask ventilation with 100% oxygen. Simultaneously, the advanced
Baseline data
From 1 January 1993 to 31 December 1998, a total of 712 out-of-hospital cardiac arrests received an attempt of resuscitation by the EMS in Innsbruck. There were 401 patients (56.6% of all cases), whose primary cardiac arrest was attributed to non-traumatic aetiology according to our inclusion criteria; of these, 108 received rt-PA. In 25.9% of them, 500 mg of acetyl salicylic acid, and in 18.5% heparin, was given in addition to rt-PA. Of the 293 controls, 216 were closely matched at a 1:2
Discussion
The results of a single city 6 year observational experience attempting to assess whether or not thrombolytic therapy may be beneficial in patients suspected of acute myocardial infarction or pulmonary embolus with out-of-hospital cardiac arrest embolism are presented. In this study, ROSC and primary survival were observed more commonly with rt-PA treatment. We are aware that survival rates for out-of-hospital cardiac arrest depend on many factors and vary widely between communities.
References (24)
- et al.
Cardiac arrest and resuscitation: a tale of 29 cities
Ann. Emerg. Med.
(1990) - et al.
Effectiveness and safety of bolus administration of alteplase in massive pulmonary embolism
Am. J. Cardiol.
(1992) - et al.
Thrombolytic therapy in patients requiring cardiopulmonary resuscitation
Am. J. Cardiol.
(1991) - et al.
Myocardial perfusion during cardiopulmonary resuscitation (CPR): effects of 10, 25, and 50% coronary stenoses
Resuscitation
(1998) - et al.
Improved thrombolysis in acute myocardial infarction with front-loaded administration of alteplase: resulsts of the rt-PA-APSAC patency study (TAPS)
J. Am. Coll. Cardiol.
(1992) Thrombolysis during cardiopulmonary resuscitation
Fibrinolysis & Proteolysis
(1997)- et al.
Predicting survival from out-of-hospital cardiac arrest: a multivariate analysis
Resuscitation
(1997) - et al.
Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction
Am. J. Cardiol.
(1992) Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC)
J. Am. Med. Assoc.
(1986)- et al.
Pre-hospital thrombolytic therapy with either alteplase or streptokinase. Practical applications, complications and long-term results in 529 patients
Eur. Heart. J.
(1995)
Rescue thrombolysis in patients with prehospital cardiopulmonary arrest and ineffective conventional resuscitation efforts
Intensivmed
Safety of thrombolysis in association with cardiopulmonary resuscitation
Br. Med. J.
Cited by (141)
Mechanical chest compression devices under special circumstances
2022, ResuscitationCitation Excerpt :It is possible that injuries caused by the device play a role in this. The use of fibrinolytics during CPR leads to increased bleeding, and can occur in up to 10% of patients.31,32 This could be exacerbated by the device use, which also tends to cause a higher rate of bleeding/haematoma compared to manual chest compressions.9
Accelerated treatment with rtPA for pulmonary embolism induced circulatory arrest
2021, Thrombosis ResearchSystemic thrombolysis for refractory cardiac arrest due to presumed myocardial infarction
2021, American Journal of Emergency MedicinePulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study)
2016, American Journal of Emergency Medicine