Elsevier

Resuscitation

Volume 73, Issue 2, May 2007, Pages 189-201
Resuscitation

Review paper
Reperfusion therapy in out-of-hospital cardiac arrest: Current insights

https://doi.org/10.1016/j.resuscitation.2006.08.030Get rights and content

Summary

Although early care in out-of-hospital cardiac arrest has been improved over the past decades, survival remains poor and neurological performance after survival is often impaired. Consequently, new therapies are needed to improve outcome. As thrombotic processes such as acute myocardial infarction or pulmonary embolism are frequent causes of cardiac arrest, therapies like fibrinolysis or percutaneous coronary intervention are of interest. Both therapies can restore coronary and pulmonary perfusion in cardiac arrest patients and, additionally, fibrinolysis might prevent microthrombi to the brain. In this review, the rationale, safety and efficacy of reperfusion therapy in patients with out-of-hospital cardiac arrest will be discussed.

Introduction

Cardiovascular disease is a major health problem in Western countries. Cardiac arrest is the first presentation in about 25%.1 In Europe, approximately 275,000 patients per year experience a cardiac arrest outside the hospital as a result of coronary artery disease, and undergo an attempt at cardiopulmonary resuscitation (CPR).2 The survival rate to hospital discharge is extremely low for out-of-hospital cardiac arrest and averages around 7%.3 Time is an important determinant of survival. For example, in patients suffering from ventricular fibrillation the chance of survival is reduced by a relative 7–10% with every minute delay to therapy.4, 5 Care for cardiac arrest patients has been improved, mainly resulting in earlier initiation of therapy, the so called optimised chain of survival: early access, early basic life support by a bystander, early defibrillation and early advanced cardiac life support.6 Despite these improvements, survival rates after cardiac arrest did not really increase as has been shown by several large registries.3, 7 In the case of survival neurological status is often impaired. Therefore, new therapies and strategies are being explored to improve outcome after cardiac arrest. As most cardiac arrests are the result of thrombotic processes, such as acute myocardial infarction or pulmonary embolism,8, 9, 10 reperfusion with fibrinolysis or percutaneous intervention is one of the therapies of interest. Although fibrinolysis has always been considered relatively contraindicated, there is increasing clinical evidence that this strategy might be relatively safe and beneficial. Also, there is evidence that percutaneous intervention might be beneficial in selected cardiac arrest patients. Both reperfusion strategies will be discussed in this article.

Section snippets

The role of fibrinolysis in cardiac arrest

Out-of-hospital cardiac arrests have both cardiac and non-cardiac causes (Figure 1).10, 11, 12, 13 It is estimated that coronary artery disease is the leading cause of cardiac arrest: 50–70% of cases are due to acute myocardial infarction (or ischaemia) triggering a life-threatening ventricular arrhythmia. Massive pulmonary embolism is a second thrombotic cause, responsible for approximately 5% of cardiac arrests, which should especially be suspected when pulseless electrical activity or

Safety of fibrinolytic therapy in cardiopulmonary resuscitation

To date, both European and American guidelines describe traumatic CPR as a relative contraindication for the use of fibrinolysis. The American guidelines additionally describe prolonged CPR (10 min) as contraindication because of fear of severe bleeding complications.16, 17 This seems plausible because fibrinolytic treatment for myocardial infarction or pulmonary embolism without the need for CPR is associated with an increased bleeding risk in comparison with controls. For example, in a large

Myocardial infarction and cardiac arrest

The incidence of acute myocardial infarction is approximately 2–3 per 1000 in Western countries and the in-hospital mortality is about 10%.26 Importantly, the true mortality rate is substantially higher, since many patients do not survive to hospital admission. One of the categories among these patients is those presenting with a cardiac arrest.

The majority of these patients will present with ventricular arrhythmias. Typically, impending ST-elevation myocardial infarction is characterised by an

Cardiac arrest and confirmed acute myocardial infarction

More than a decade ago fibrinolysis was already considered an acceptable therapy in patients who presented with myocardial infarction and in whom subsequently CPR was required. Nonetheless, in these patients fibrinolysis was also considered potentially harmful: the risk of fatal haemorrhage was thought to be increased considerably. In most of the individual trials, fibrinolysis showed a non-significant increase in the risk of bleeding (Table 1).20, 21, 22, 23 A recent meta-analysis of these

PCI in cardiac arrest

In ST-elevation myocardial infarction without cardiac arrest, primary percutaneous coronary intervention has been shown to be very effective in lowering morbidity and mortality.55 Moreover, the risk of bleeding is lower in comparison with fibrinolysis. In cardiac arrest, coronary angioplasty could be an attractive strategy, but data are scarce.

Recently, a retrospective study was conducted addressing the feasibility of percutaneous coronary intervention in cardiac arrest. Forty patients

Conclusion

The evidence available from several observational, mostly non-randomised studies reveals that fibrinolytic therapy has potential as additional treatment during cardiopulmonary resuscitation in patients suffering from non-traumatic out-of-hospital cardiac arrest. Post hoc observations in CPR patients with confirmed acute myocardial infarction or pulmonary embolism provide a proof of concept. Yet, in the acute setting every minute lost in the diagnostic process could result in a marked decrease

Conflict of interest

None.

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  • Cited by (0)

    A Spanish translated version of the summary of this article appears as Appendix in the final online version at 10.1016/j.resuscitation.2006.08.030.

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