Can Systemic Thrombolysis Improve Prognosis of Cardiac Arrest Patients During Cardiopulmonary Resuscitation? A Systematic Review and Meta-Analysis

Management of high-risk pulmonary embolism in the emergency department: A narrative review

BACKGROUND

High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE.

OBJECTIVE

This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations.

DISCUSSION

High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions.

CONCLUSIONS

Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.

Role of adjunct anticoagulant or thrombolytic therapy in cardiac arrest without ST-segment-elevation or percutaneous coronary intervention: A systematic review and meta-analysis

This study sought to compare the impact of additional anticoagulation or thrombolytic therapy in patients with cardiac arrest without ST-segment-elevation on electrocardiography and not receiving percutaneous coronary intervention. Three studies (two randomized controlled studies and one observational study) were included, which demonstrated that use of anticoagulation or thrombolytic therapy was associated with higher risk of bleeding, without improvements in time to return of spontaneous circulation or in-hospital mortality.

An Update on the Management of Acute High-Risk Pulmonary Embolism

Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.

Thrombolytic therapy in cardiac arrest caused by cardiac etiologies or presumed pulmonary embolism: An updated systematic review and meta-analysis

Background

Many cardiac arrest cases are encountered annually worldwide, with poor survival. The use of systemic thrombolysis during cardiopulmonary resuscitation for the treatment of cardiac arrest remains controversial.

Objectives

Evaluate the safety and efficacy of systemic thrombolysis in patients with cardiac arrest due to presumed or confirmed pulmonary embolism or cardiac etiology.

Methods

We searched the PubMed and Cochrane databases from inception through April 2021 to identify relevant randomized controlled trials and observational studies. The primary efficacy and safety outcomes were survival to hospital discharge and reported bleeding, respectively. Sensitivity analysis was performed on the basis of study design and etiology of cardiac arrest.

Results

Eleven studies were included, with 4696 patients (1178 patients received systemic thrombolysis, and 3518 patients received traditional therapy). There was a higher rate of survival to hospital discharge in patients who received systemic thrombolysis versus no systemic thrombolysis (risk ratio [RR], 1.35; 95% confidence interval [CI], 0.95-1.91). There were also higher rates of survival at 24 hours (RR, 1.24; 95% CI, 0.97-1.59) and hospital admission (RR, 1.53; 95% CI, 1.04-2.24), and return of spontaneous circulation (ROSC) (RR, 1.34; 95% CI, 1.05-1.71) with the use of systemic thrombolysis. Impacts on survival to discharge and survival at 24 hours were not statistically significant. Patients receiving systemic thrombolysis had a 65% increase in bleeding events compared with no systemic thrombolysis (RR, 1.65; 95% CI, 1.20-2.27).

Conclusion

Systemic thrombolysis in cardiac arrest did not improve survival to hospital discharge and led to more bleeding events. However, it increased the rates of hospital admission and ROSC achievement.

Early cardiopulmonary resuscitation on serum levels of myeloperoxidase, soluble ST2, and hypersensitive C-reactive protein in acute myocardial infarction patients

BACKGROUND

Prompt and effective cardiopulmonary resuscitation (CPR) can promote the recovery of spontaneous circulation to some extent and can save patients’ lives. The minimum target of cardiac resuscitation is the restoration of spontaneous circulation (ROSC). However, owing to prolonged sudden cardiac arrest, there is relatively high mortality within 24 h after cardiac resuscitation. Moreover, severe cerebral anoxia can deteriorate the prognosis of patients. Therefore, it is important to adopt an effective clinical evaluation of acute myocardial infarct (AMI) patients’ prognosis after cardiac resuscitation for the purpose of prevention and management.

AIM

To investigate early CPR effects on human myeloperoxidase (MPO), soluble ST2 (sST2), and hypersensitive C-reactive protein (hs-CRP) levels in AMI patients.

METHODS

In total, 54 patients with cardiac arrest caused by AMI in our hospital were selected as the observation group, and 50 other patients with AMI were selected as the control group. The differences in serum levels of MPO, sST2, and hs-CRP between the observation group and the control group were tested, and the differences in the serum levels of MPO, sST2, and hs-CRP in ROSC and non-ROSC patients, and in patients who died and in those who survived, were analyzed.

RESULTS

Serum levels of MPO, sST2, hs-CRP, lactic acid, creatine kinase isoenzyme (CK-MB), and cardiac troponin I (cTnI) were significantly higher in the observation group than in the control group (P < 0.05). Serum levels of MPO, sST2, hs-CRP, lactic acid, CK-MB, and cTnI in the observation group were lower after CPR than before CPR (P < 0.05). In the observation group, MPO, sST2, hs-CRP, lactic acid, CK-MB, and cTnI serum levels were lower in ROSC patients than in non-ROSC patients (P < 0.05). MPO, sST2, hs-CRP, and lactic acid serum levels of patients who died in the observation group were higher than those of patients who survived (P < 0.05). The areas under receiver operating characteristic curve predicted by MPO, sST2, hs-CRP, lactic acid, CK-MB, and cTnI were 0.616, 0.681, 0.705, 0.704, 0.702, and 0.656, respectively (P < 0.05). The areas under receiver operating characteristic curve for MPO, SST2, hs-CRP, and lactic acid to predict death were 0.724, 0.800, 0.689, and 0.691, respectively (P < 0.05). Logistic regression analysis showed that MPO, sST2, and hs-CRP were the influencing factors of ROSC [odds ratios = 1.667, 1.589, and 1.409, P < 0.05], while MPO, sST2, hs-CRP, and lactic acid were the influencing factors of death (odds ratios = 1.624, 1.525, 1.451, and 1.365, P < 0.05).

CONCLUSION

Serum levels of MPO, sST2, hs-CRP, and lactic acid have a certain value in predicting recovery and prognosis of patients with ROSC.

Drug use during adult advanced cardiac life support: An overview of reviews

AIM

To conduct an overview of systematic reviews and meta-analyses to summarize the ever-growing evidence on drug use during advanced life support.

METHODS

We searched Embase, Medline, Cochrane central register of controlled trials and Web of science for systematic reviews and meta-analyses reporting on drug use during advanced life support from inception to March, 2020. Two reviewers independently assessed all abstracts for eligibility, extracted data and assessed risk of bias using the AMSTAR-2 tool. Corrected covered areas were calculated from publication citation matrices to account for potential risk of bias. Data were graphically represented using forest plots.

RESULTS

Twenty-two head-to-head drug comparisons from 47 included articles were analysed. Adrenaline significantly increases the incidence of return of spontaneous circulation and survival to hospital discharge, but not the incidence of neurological intact survival. Vasopressin alone or in combination with adrenaline is not superior to adrenaline alone. There is a trend favouring lidocaine over amiodarone in shockable cardiac arrest. The risk of bias assessment of included studies ranged from very low to very high and the overlap between articles was moderate to high.

CONCLUSIONS

In line with the guidelines, we currently suggest that a standard dose of adrenaline should be administered during resuscitation, however, studies assessing lower doses of adrenaline are pressing. There is no rationale for the combination of vasopressin and adrenaline or vasopressin alone instead of adrenaline. In addition, lidocaine is a valuable alternative for amiodarone and maybe even preferable for shockable cardiac arrest. However more research is necessary.

ST-Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest

5-10% of ST-elevated myocardial infarctions (STEMI) present with out-of-hospital cardiac arrest (OHCA). Although this subgroup of patients carries the highest in-hospital mortality among the STEMI population, it is the least likely to undergo coronary angiography and revascularization. Due to the concomitant neurologic injury, patients with OHCA STEMI require prolonged hospitalization and adjustments to standard MI management. This review systematically assesses the course of patients with OHCA STEMI from development of the arrest to hospital discharge, assesses the limiting factors for their treatment access, and presents the evidence-based optimal intervention strategy for this high-risk MI population.

Systemic thrombolysis for refractory cardiac arrest due to presumed myocardial infarction

The empiric usage of systemic thrombolysis for refractory out of hospital cardiac arrest (OHCA) is considered for pulmonary embolism (PE), but not for undifferentiated cardiac etiology [1, 2]. We report a case of successful resuscitation after protracted OHCA with suspected non-PE cardiac etiology, with favorable neurological outcome after empiric administration of systemic thrombolysis. A 47-year-old male presented to the emergency department (ED) after a witnessed OHCA with no bystander cardiopulmonary resuscitation (CPR). His initial rhythm was ventricular fibrillation (VF) which had degenerated into pulseless electrical activity (PEA) by ED arrival. Fifty-seven minutes into his arrest, we gave systemic thrombolysis which obtained return of spontaneous circulation (ROSC). He was transferred to the coronary care unit (CCU) and underwent therapeutic hypothermia. On hospital day (HD) 4 he began following commands and was extubated on HD 5. Subsequent percutaneous coronary intervention (PCI) revealed non-obstructive stenosis in distal LAD. He was discharged home directly from the hospital, with one-month cerebral performance category (CPC) score of one. He was back to work three months post-arrest. Emergency physicians (EP) should be aware of this topic since we are front-line health care professionals for OHCA. Thrombolytics have the advantage of being widely available in ED and therefore offer an option on a case-by-case basis when intra-arrest PCI and ECPR are not available. This case report adds to the existing literature on systemic thrombolysis as salvage therapy for cardiac arrest from an undifferentiated cardiac etiology. The time is now for this treatment to be reevaluated.