Thrombolytic therapy in patients requiring cardiopulmonary resuscitation

Abstract

Cardiopulmonary resuscitation (CPR) is often considered a contraindication to thrombolytic therapy for acute myocardial infarction. Of 708 patients involved in the first 3 Thrombolysis and Angioplasty in Myocardial Infarction trials of lytic therapy for acute infarction, 59 patients required less than 10 minutes of CPR before receiving lytic therapy (CPR greater than 10 minutes was an exclusion of the trials) or required CPR within 6 hours of treatment. The patients receiving CPR were similar to the remainder of the group with respect to baseline demographics. The indication for CPR was usually ventricular fibrillation (73%) or ventricular tachycardia (24%). The median duration of CPR was 1 minute, with twenty-fifth and seventy-fifth percentiles of 1 and 5 minutes, respectively. The median number of cardioversions/defibrillations performed was 2 (twenty-fifth and seventy-fifth percentiles of 1 and 3 minutes, respectively). Patients receiving CPR were more likely to have anterior infarctions (66 vs 39%), the left anterior descending artery as the infarct-related artery (63 vs 38%) and lower ejection fractions on the initial ventriculogram (46 +/- 11 vs 52 +/- 12%) than those not receiving CPR. In-hospital mortality was 12 vs 6% with most deaths due to pump failure (57%) or arrhythmia (29%) in the CPR group and pump failure (38%) or reinfarction (25%) in the non-CPR group. At 7 day follow-up the CPR group had a significant increase in ejection fraction (+5 +/- 9%) compared with no change in non-CPR group. There were no bleeding complications directly attributed to CPR.(ABSTRACT TRUNCATED AT 250 WORDS)

Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment

“…In the nonthrombolysis group we observed major bleeding complications in seven of 133 patients (5%, 95% confidence interval 1-9%) (patient nos [14][15][16][17][18][19][20]. In patient 14 (CPR duration 12 min) the X-ray revealed left-sided fluidopneumothorax without signs of tension as major complication.…”

“…In a retrospective analysis, Tenaglia et al [18] studied 59 patients after short duration of CPR (<10 min), 37 of whom required only defibrillation, excluding patients with a resuscitation procedure lasting more than 10 min They found no direct complications of thrombolytic therapy and concluded that thrombolytic treatment after short duration of CPR is safe and effective. Weston and Avery [20] found three significant bleeding complications after thrombolysis in a group of 16 patients, all of these patients survived to hospital discharge.…”

“…Only some case reports and small case series provided data regarding the safety and efficacy of systemic thrombolytic treatment in patients who suffered cardiac arrest caused by AMI [13][14][15][16][17][18][19][20]. Some authors consider CPR to be a relative contraindication for thrombolysis, irrespective of the duration of CPR, whilst others consider only prolonged CPR a contraindication.…”

Thrombolytic therapy for acute myocardial infarction

“…Two series comprising a total of 102 patients treated with CPR for durations ranging from 4 -120 min, however, found no increased incidence of major or minor bleeding complications [33,34]. Thus, in the absence of obvious chest wall trauma or anoxic brain injury (the latter would theoretically increase the risk of intracranial hemorrhage), CPR should not be considered a contraindication to thrombolysis.…”

III Diretriz sobre tratamento do infarto agudo do miocárdio

“…O consenso até o momento é de que se a ressuscitação cardiopulmonar foi de curta duração e aparentemente atraumática, o medicamento pode ser administrado. Alguns relatos de administração de trombolíticos na parada cardiorrespiratória após infarto do miocárdio ou embolia pulmonar maciça têm evidenciado resultados animadores, mesmo III Diretriz sobre Tratamento do Infarto Agudo do Miocárdio quando essa terapêutica é utilizada como recurso extremo após falha nas medidas habituais e com ressuscitação prolongada [654][655][656][657][658][659][660][661] . A possível explicação para os efeitos benéficos é que, ao lado de sua ação no processo causal, dissolução do trombo coronariano e/ou de êmbolo arterial pulmonar, haveria incremento da reperfusão na microcirculação, principalmente em território cerebral 662 , como demonstram estudos experimentais 663 , o que permitiria a recuperação com menor dano cerebral.…”