Fibrinolysis in cardiac arrest

6 Dec

Review article by Baptista SB et al.:

RE: Fibrinolysis in cardiac arrest of undetermined cause

–2001 Lederer et al. retrospective analysis (some selection bias, uneven groups –alteplase group was significantly younger)

  • 401 patients with out of-hospital cardiac arrest
  • 108 of whom were treated with alteplase.
  • ROSC (70.4% vs. 51.0 %; p = 0.001), surviving at 24 hours (48.13 % vs. 32.9 %; p = 0.003), and surviving at discharge (25.0% vs. 15.3 %; p = 0.048), were all significantly higher in patients treated with alteplase.
  • No difference was observed in the number of hemorrhagic complications.

 

–2001 Böttiger et al. prospective randomized trial

  • 90 patients with out-of-hospital cardiac arrest (50 in control group, 40 got alteplase)
  • After 15 minutes of unsuccessful resuscitation, experimental group received a bolus of 5000 units of heparin and 50 U of alteplase (repeated 30 minutes later if there was no ROSC).
  • No differences in hemorrhagic complications.
  • alteplase group had higher ROSC (68% vs. 44 %, p = 0.026) and admission to intensive care (58% vs. 30 %, p = 0.009)
  • non-statistically significant tendency for improved 24 hour survival (35 % vs. 22 %) and discharge from hospital (15% vs. 8%)

 

–2002 Abu-Laban et a. prospective randomized double-blind trial

  • cardiac arrest of undetermined cause (presumed cardiovascular).
  • Only patients with PEA were included
  • 233 patients randomized to infusion of 100 mg alteplase over 15 minutes or to placebo.
  • No significant differences in:
    • the number of patients with ROSC (21.4% vs. 23.3 %),
    • number of patients taken to hospital (33.3% vs. 32.8 %),
    • survival at admission (6.0% vs. 5.2 %)
    • hospital discharge (0.9 vs. 0.0 %).
    • serious hemorrhagic complications (1.7% vs. 0.0 %).
  • Autopsy, performed in 18 % of the patients, revealed prevalences of AMI and pulmonary embolism of only 21.4% and 2.4% respectively

 

10-SECOND RECAP:

limited data, zero-to-some trend, +/- significance, toward improved ROSC, survival to discharge in alteplase group in cardiac arrest

–so maybe some clinical benefit, “no unacceptable risk for hemorrhage during resuscitation”

–not all arrests are thrombus, but ‘you can’t kill dead’ (as JSH might say)

 

 

References: pubmed link; direct link; picture

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