Thrombolysis during Resuscitation
NEJM 2008 Dec. B.W. Bottiger et al: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest.
In this randomized, double-blind, multicenter trial, adult patients with witnessed out-of-hospital cardiac arrest were assigned to receive either tenecteplase (thrombolytic agent) or placebo during resuscitation. The use of heparin, clopidogrel, ticlodipine, and aspirin were discouraged and the use of glycoprotein IIb/IIIa inhibitors was not permitted in this study. The researchers observed no significant differences between the tenecteplase and placebo groups in the efficacy end points that were evaluated, including the primary end point of 30-day survival and the secondary end points of return of spontaneous circulation, hospital admission, 24-hour survival, survival to hospital discharge, and neurologic outcome. However, the researchers do state the following: “Our findings do not suggest that thrombolytic therapy should be withheld in patients with cardiac arrest if the primary pathologic condition is known to be responsive to such treatment.”
Clinical Pearl Intracranial Hemorrhage and Thrombolysis
One of the biggest risk factors associated with the use of thrombolytic agents is intracranial hemorrhage. In this study, intracranial hemorrhage occurred with significantly greater frequency in the tenecteplase group (14 of 518 [2.7%]) than in the placebo group (2 of the 514 [0.4%], P=0.006). Four patients with intracranial hemorrhage (all in the tenecteplase group) were symptomatic.
Guidelines for Use of Thrombolytics in Cardiac Arrest
Current cardiopulmonary-resuscitation guidelines state that thrombolytic therapy should be considered in adult patients who have cardiac arrest with pulmonary embolism but there are insufficient data to make a recommendation for or against the use of thrombolysis in cardiac arrest. (American Heart Association Guidelines, Circulation, 2005.)