Thrombolysis In Cardiac Arrest Research Articles

Cerebrovascular events and thrombolysis in pulmonary embolism-induced cardiac arrest: a case series and key challenges

Background and purposeCerebrovascular events during thrombolysis in cardiac arrest (CA) caused by pulmonary embolism (PE) is a life-threatening condition. However, the balance between cerebrovascular events and thrombolytic therapy in PE-induced CA remains a great challenge.MethodsIn this study, we reported three unique cases regarding main concerns surrounding cerebrovascular events in thrombolytic therapy in PE-induced CA.ResultsThe patient in the case 1 treated with thrombolysis during CPR and finally discharged neurologically intact. The patient in the case 2 received delayed thrombolysis and died eventually. The patient in the case 3 was contraindicated to thrombolysis due to the complication of subarachioid hemorrahage and died within days.ConclusionsOur case series highlights three proposed approaches to consider before administering thrombolysis as a treatment option in PE-induced CA patients: (1) prolonging the resuscitation, (2) administering thrombolysis promptly, and (3) ruling out cerebrovascular events.

Thrombolytic therapy in cardiac arrest caused by cardiac etiologies or presumed pulmonary embolism: An updated systematic review and meta‐analysis

BackgroundMany cardiac arrest cases are encountered annually worldwide, with poor survival. The use of systemic thrombolysis during cardiopulmonary resuscitation for the treatment of cardiac arrest remains controversial. ObjectivesEvaluate the safety and efficacy of systemic thrombolysis in patients with cardiac arrest due to presumed or confirmed pulmonary embolism or cardiac etiology. MethodsWe searched the PubMed and Cochrane databases from inception through April 2021 to identify relevant randomized controlled trials and observational studies. The primary efficacy and safety outcomes were survival to hospital discharge and reported bleeding, respectively. Sensitivity analysis was performed on the basis of study design and etiology of cardiac arrest. ResultsEleven studies were included, with 4696 patients (1178 patients received systemic thrombolysis, and 3518 patients received traditional therapy). There was a higher rate of survival to hospital discharge in patients who received systemic thrombolysis versus no systemic thrombolysis (risk ratio [RR], 1.35; 95% confidence interval [CI], 0.95‐1.91). There were also higher rates of survival at 24 hours (RR, 1.24; 95% CI, 0.97‐1.59) and hospital admission (RR, 1.53; 95% CI, 1.04‐2.24), and return of spontaneous circulation (ROSC) (RR, 1.34; 95% CI, 1.05‐1.71) with the use of systemic thrombolysis. Impacts on survival to discharge and survival at 24 hours were not statistically significant. Patients receiving systemic thrombolysis had a 65% increase in bleeding events compared with no systemic thrombolysis (RR, 1.65; 95% CI, 1.20‐2.27). ConclusionSystemic thrombolysis in cardiac arrest did not improve survival to hospital discharge and led to more bleeding events. However, it increased the rates of hospital admission and ROSC achievement.

Usefulness of thrombolysis in cardiac arrest secondary to suspected or confirmed pulmonary embolism

Acute pulmonary embolism (PE) is a form of venous thromboembolism associated with significant morbidity and mortality. Massive PE, characterized by hemodynamic instability, has been reported as a common cause of cardiac arrest. Thrombolytic agents have therefore been identified as a potential rescue therapy to restore circulatory perfusion. This study describes use patterns of systemic thrombolysis in cardiac arrest and corresponding patient outcomes. A multicenter retrospective chart review was conducted to evaluate adult patients who received rescue thrombolysis during cardiac arrest for suspected or confirmed PE. A total of 27 patients were included. PE was confirmed in 4 patients (15%). Pulseless electrical activity was the initial rhythm in 21 patients (78%), with a median cardiac arrest duration of 23 minutes in patients with return of spontaneous circulation (ROSC) vs 42.5 minutes in patients without ROSC. Among the 11 patients (41%) with ROSC, two (7%) survived to hospital discharge. Notable characteristics of the two survivors included a confirmed PE, an initial presenting rhythm of pulseless electrical activity, and administration of alteplase within 5 minutes of cardiac arrest. We recommend early administration of rescue thrombolysis when there is a high clinical index of suspicion that PE is the cause of the arrest.

“Real-World” Application of Thrombolysis in Cardiac Arrest

Background: Current guidelines recommend consideration of thrombosis as a reversible cause of cardiac arrest. The use of thrombolytic therapy during cardiac arrest, however, is controversial. Objective: We sought to characterize the use of thrombolytic therapy during cardiac arrest and to evaluate the rate of return of spontaneous circulation (ROSC) in a “real-word” setting. Methods: A single-center, retrospective, cohort study of adult patients who received alteplase during cardiac arrest between 2010 and 2015 were performed at a tertiary academic medical center. Results: Twenty-six patients were identified. Patients were predominantly male (65%) and Caucasian (89%) and were a median age of 64 years. Five patients had a history of preexisting venous thromboembolism, and eight patients were receiving systemic anticoagulation. Pulmonary embolism was confirmed prior to the administration of alteplase in 5 patients. The median dose of alteplase administered was 100 mg. ROSC was achieved in 65% of patients, 2 of whom survived to hospital discharge. Both surviving patients experienced a bleeding event. Conclusion: In a single center’s experience, thrombolytic therapy is used infrequently for the management of cardiac arrest. Thrombolysis during cardiac arrest should be considered on a case-by-case basis and should be utilized only when there is a high suspicion for pulmonary embolism as the cause of arrest and when thrombolytic therapy is readily available.

Impact of fibrinolysis on immediate prognosis of patients with out-of-hospital cardiac arrest

Fibrinolytic therapy (FT) during out-of-hospital cardiac arrest (OHCA) has been studied in several trials, but they have produced unsatisfactory results even in the most recent Thrombolysis in Cardiac Arrest (TROICA) study. This study aimed to assess the impact of FT provided by an out-of-hospital emergency physician on the immediate prognosis of patients with OHCA. We performed a retrospective study in which the primary endpoint was survival to hospital admission. Among 5,102 patients with OHCA in Paris and the suburban area who received medical care from the Fire Brigade of Paris, 1,261 met the following inclusion criteria: age above 18years with non-traumatic OHCA. Among 107 patients who received FT, 51 (47.7%) survived to hospital admission whereas 272 out of 1,154 (23.6%) patients who did not receive FT survived to hospital admission. A matching process based on a propensity score used to equalise potential prognosis factors in both groups demonstrated that FT was associated with more frequent survival to hospital admission (OR adjusted: 1.7; CI 95% [1.09-2.68]). This result was observed particularly in patients who were not initially shocked by automatic electrical defibrillator (AED) (OR(a)=3.61; CI 95% [1.88-6.96]). This study showed that fibrinolysis was associated with improved survival to hospital admission, after performing a propensity analysis. FT may be beneficial in out-of-hospital arrest patients. However, any conclusions drawn are limited by the retrospective nature of the study.

Thrombolysis for Prevention of Cerebral No-Reflow After Cardiopulmonary Resuscitation

Thrombolytic treatment during cardiopulmonary resuscitation is thought to reverse the cerebral no-reflow phenomenon which is widely considered to limit neurological recovery after prolonged cardio-circulatory arrest. However, the recent multicenter randomized double-blind TROICA (Thrombolysis in Cardiac Arrest) trial revealed that patients with witnessed out-of-hospital cardiac arrest did not experience an improvement of neurological outcome when treated with the throm-bolytic agent tenecteplase [1]. This raises the question of the importance of coagulation disturbances in the pathophysiol-ogy of no-reflow and its reversal by thrombolytic interventions. This article provides an overview of the experimental literature on this subject.

Recently published papers: A series of negative results

Studies with negative results rarely hit the headlines. But the results are often just as important as the positive ones. A number of 'negative headline' studies are looked at in this review: intensive insulin therapy regime, thrombolysis in cardiac arrest, the effects of nutritional guidelines and rapid response outreach teams.

Post–Cardiac Arrest Syndrome

The contributors to this statement were selected to ensure expertise in all the disciplines relevant to post–cardiac arrest care. In an attempt to make this document universally applicable and generalizable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post–cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations took place initially by e-mail, followed a series of telephone conferences and face-to-face meetings of the cochairs and writing group members. International writing teams were formed to generate the content of each section, which corresponded to the major subheadings of the final document. Two team leaders from different countries led each writing team. Individual contributors were assigned by the writing group cochairs to work on 1 or more writing teams, which generally reflected their areas of expertise. Relevant articles were identified with PubMed, EMBASE, and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Drafts of each section were written and agreed on by the writing team authors and then sent to the cochairs for editing and amalgamation into a single document. The first draft of the complete document was circulated among writing team leaders for initial comment and editing. A revised version of the document was circulated among all contributors, and consensus was achieved before submission of the final version for independent peer review and approval for publication. This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimization of post–cardiac arrest care and to pinpoint the need for research focused on gaps in knowledge that would potentially improve outcomes …

International multicentre trial protocol to assess the efficacy and safety of tenecteplase during cardiopulmonary resuscitation in patients with out‐of‐hospital cardiac arrest: The Thrombolysis in Cardiac Arrest (TROICA) Study

Prehospital cardiac arrest has been associated with a very poor prognosis. Acute myocardial infarction and massive pulmonary embolism are the underlying causes of out-of-hospital cardiac arrest in 50-70% of patients. Although fibrinolysis is an effective treatment strategy for both myocardial infarction and pulmonary embolism, clinical experience for this therapy performed during resuscitation has been limited owing to the anticipated risk of severe bleeding complications. The TROICA study is planned as one of the largest randomized, double-blind, placebo-controlled trials to assess the efficacy and safety of prehospital thrombolytic therapy in cardiac arrest of presumed cardiac origin. Approximately 1000 patients with cardiac arrest will be randomized at approximately 60 international study centres to receive either a weight-adjusted dose of tenecteplase or placebo after the first dose of a vasopressor. Patients can be included if they are at least 18 years, presenting with a witnessed cardiac arrest of presumed cardiac origin, and if either basic life support had started within 10 min of onset and had been performed up to 10 min or advanced life support is started within 10 min of onset of cardiac arrest. Primary endpoint of the study is the 30-day survival rate, and the coprimary endpoint is hospital admission. Secondary endpoints are the return of spontaneous circulation (ROSC), survival after 24 h, survival to hospital discharge, and neurological performance. Safety endpoints include major bleeding complications and symptomatic intracranial haemorrhage.

Thrombosis after cardiac arrest

I read with interest the article by Fatovich et al. on thrombolysis after cardiac arrest [[1]Fatovich D.M. Dobb G.J. Clugston R.A. A pilot randomised trial of thrombolysis in cardiac arrest (the TIC A trial).Resuscitation. 2004; 61: 309-313Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. The authors describe a modest improvement in restoration of spontaneous circulation (ROSC) in favor of tenectaplase, although survival to discharge was not improved. As it is possible that that temporary myocardial perfusion was established through thrombolysis and allowed for ROSC, the results are more valid from a cardiological point of view. The ROSC achieved does not impact on neuronal integrity or survival to discharge which is unaltered. The effect would have been more significant if treatment arms contained equal proportions of ‘shockable rhythms’ (VT or VF) and ‘unshockable rhythms’ (asystole or PEA). ROSC is more common with VF (58%) than in patients with pulseless electrical activity (PEA) (35–39%). Similarly ‘shockable rhythms have a better survival rate to discharge (34%) compared to ‘unshockable rhythms’ (<10%) [[2]Peberdy M.A. Kaye W. Ornato J.P. et al.Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation.Resuscitation. 2003; 58: 297-308Abstract Full Text Full Text PDF PubMed Scopus (945) Google Scholar]. ROSC by itself cannot be an endpoint of treatment as there is a large attrition in numbers surviving to discharge. The ideal long-term aim of thrombolysis in addition to ROSC should be to improve cerebral blood flow and offset an immediate no-reflow phenomenon seen in the cerebral circulation. Among the study arms there was a 44% difference in VF among the treatment and placebo group. With the evidence obtained from prior studies, it is immediately evident that ROSC would be more frequent in the treatment arm, which had a higher number of patients with ‘shockable rhythms’. This would explain the short term benefit seen in the study. Moreover the treatment arm consisted of younger patients. Age has also a great impact on ROSC with poorer survival rates in older patients (>70 years) [[3]Gwinnutt C.L. Columb M. Harris R. Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines.Resuscitation. 2000; 47: 125-135Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar]. These two factors have to be incorporated into any new prospective trial of thrombolysis after cardiac arrest.

A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial)

A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial)

Thrombolysis as a Therapeutic Modality in Cardiac Arrest

Introduction In recent years, thrombolysis has emerged as a potentially promising treatment for cardiac arrest. Patients with cardiac arrests from myocardial infarction or pulmonary embolism, as well as out-of-hospital cardiac arrests, were reported to have improvement in both survival and neurologic outcome after being treated with thrombolysis. This paper aims to review the available literature on the use of thrombolysis in cardiac arrest. Method Study of papers from PubMed literature search for all articles with terms related to thrombolysis and cardiac arrest in title or abstract. Results Thrombolytics are thought to act by lysing both macroscopic clots and microthrombi, particularly in the cerebral microcirculation, thus alleviating or reversing post-arrest cerebral no-reflow. Their use in cardiac arrest has been restrained by concerns over their safety after cardiopulmonary resuscitation, in particular bleeding-related complications, although these concerns seem to have been misplaced. Conclusions Thrombolysis for cardiac arrest is likely to be most efficacious in a pre-hospital environment, and future research should be directed to this setting.

Is t-PA of Value in Cardiac Arrest?

There are numerous anecdotal reports in the literature and in every emergency department about the value of thrombolysis in cardiac arrest. Noting that

Role of thrombolysis in cardiac arrest.

Role of thrombolysis in cardiac arrest.