Review paperReperfusion therapy in out-of-hospital cardiac arrest: Current insights☆
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.
References (59)
- et al.
Incidence of EMS-treated out-of-hospital cardiac arrest in Europe
Resuscitation
(2005) - et al.
Creatine kinase-mb fraction and cardiac troponin T to diagnose acute myocardial infarction after cardiopulmonary resuscitation
J Am Coll Cardiol
(1996) - et al.
Causes and prognosis of cardiac arrest in a population admitted to a general hospital; a diagnostic and therapeutic problem
Resuscitation
(2003) - et al.
The cerebral ‘no-reflow’ phenomenon after cardiac arrest in rats—influence of low-flow reperfusion
Resuscitation
(1997) - et al.
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the management of patients with acute myocardial infarction)
J Am Coll Cardiol
(2004) Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients
Lancet
(1994)- et al.
Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction
Am J Cardiol
(1992) - et al.
Thrombolytic therapy in patients requiring cardiopulmonary resuscitation
Am J Cardiol
(1991) - et al.
Major bleeding complications in cardiopulmonary resuscitation: the place of thrombolytic therapy in cardiac arrest due to massive pulmonary embolism
Resuscitation
(2003) - et al.
Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest
Resuscitation
(2001)
A meta-analysis of cardiopulmonary resuscitation with and without the administration of thrombolytic agents
Resuscitation
Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the US from 1990 through 1999: The National Registry of Myocardial Infarction 1, 2 and 3
J Am Coll Cardiol
Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest
Resuscitation
Incidence and prognosis of early primary ventricular fibrillation in acute myocardial infarction–results of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI-2) database
Am J Cardiol
The influence of cardiopulmonary resuscitation without defibrillation on serum levels of cardiac enzymes: a time course study of out-of-hospital cardiac arrest survivors
Resuscitation
The influence of chest compressions and external defibrillation on the release of creatine kinase-MB and cardiac troponin T in patients resuscitated from out-of-hospital cardiac arrest
Resuscitation
Outcome after cardiac arrest: predictive values and limitations of the neuroproteins neuron-specific enolase and protein S-100 and the Glasgow Coma Scale
Resuscitation
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome
Resuscitation
Long-term survival and neurological outcome of patients who received recombinant tissue plasminogen activator during out-of-hospital cardiac arrest
Resuscitation
Safety and efficacy of thrombolysis for acute myocardial infarction in patients with prolonged out-of-hospital cardiopulmonary resuscitation
Am J Cardiol
Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a prospective clinical trial
Lancet
Effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation
Am J Cardiol
A pilot randomised trial of thrombolysis in cardiac arrest (the TICA trial)
Resuscitation
Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials
Lancet
Long-term prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention
Resuscitation
Decrease in the occurrence of ventricular fibrillation as the initially observed arrhythmia after out-of-hospital cardiac arrest during 11 years in Sweden
Resuscitation
Massive pulmonary embolism: percutaneous mechanical thrombectomy during cardiopulmonary resuscitation
J Vasc Interv Radiol
Cardiac resuscitation
N Engl J Med
Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Goteborg, Sweden
Heart
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.