European Heart Journal Advance Access originally published online on October 24, 2008
European Heart Journal 2008 29(24):3067-3068; doi:10.1093/eurheartj/ehn475
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Thrombolysis during cardiopulmonary resuscitation should be addressed in guidelines for pulmonary embolism: reply
Department of Chest Medicine
Institute of Tuberculosis and Lung Disease
ul Plocka 26
01-138 Warszawa
Poland
Tel: +48 22 691 2114
Fax: +48 22 691 2414
Email: a.torbicki{at}igichp.edu.pl
Medical Clinic 1
Geneva University Hospital
Geneva
Switzerland
Department of Cardiology and Pulmonary Medicine
Georg August University of Goettingen
Goettingen
Germany
for the ESC Task Force on Diagnosis and Management of Pulmonary Embolism
Dr Koracevic raised an interesting point, suggesting that thrombolysis should be recommended in patients with PE who present with cardiac arrest. Indeed, if caused by PE, cardiac arrest is indicating the highest risk of early death. And resuscitation is no longer considered an important contraindication to thrombolytic treatment.1 The problem is in diagnosing PE in the setting of cardiac arrest.
Thrombolytic treatment was suggested to increase the chances of survival in unselected patients with cardiac arrest. However, encouraging preliminary reports and a metaanalysis of eight trials including 926 patients2 were not confirmed by a large multicentre study. In fact, the TROICA trial was discontinued in April 2006 after enrolling over 1000 patients because the preliminary data analysis indicated that it would be unlikely to demonstrate the superiority of tenecteplase over placebo during cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest.3 Importantly, the study was not stopped due to safety issues; the intracranial haemorrhage rate was within the expected range for fibrinolytic treatment.
This, of course, does not exclude that thrombolytic treatment could still be a valid option during CPR in selected patients with cardiac arrest and particularly in those in whom pulmonary embolism is clinically suspected.4 The critical question is how to identify these patients. A randomized trial including 233 patients in cardiac arrest with episodes of pulseless electrical activity, considered as potentially suggestive of PE, failed to find any benefit in the alteplase arm compared with placebo.5 Moreover, the prevalence of PE in patients who underwent autopsy was unexpectedly low.
One can argue that circumstances preceding the event might be useful to increase the suspicion of PE.4 Unfortunately, reliable information is rarely available, especially in outpatient setting. It would thus be difficult to venture any formal recommendations, also defining what kind of information and from what sources could be considered sufficient to justify thrombolysis. Even a patient currently treated for recent PE may suffer cerebral bleeding and not necessarily early recurrence.
Therefore, similar to suspected high-risk PE presenting with hypotension or shock, some objective data collection should be attempted. Van der Wouw et al.6 reported on the successful use of transesophageal echocardiography (TEE) in the setting of CPR both in prolonged out-of-hospital and in-hospital cardiac arrest. Interestingly, among 48 studied cases, TEE found signs suggestive of PE in six patients, while cardiac tamponade was documented in six others, aortic dissection in five, and rupture in one patient. This highlights the importance of differential diagnosis also in such dramatic circumstances.
In summary, although PE is suspected in every case of cardiac arrest, there are no specific criteria justifying the routine use of thrombolysis in the setting of CPR. There is no evidence that thrombolysis is beneficial in unselected patients, and also in those in whom pulseless electrical activity is recorded during CPR. The use of bedside echocardiography, including TEE, and venous ultrasonography should be encouraged as in other patients with suspected high-risk PE if CT angiography is not an option. Management decisions should be taken based on all collected data on a case-by-case basis.
References
- Keuper W, Dieker HJ, Brouwer MA, Verheugt FW. Reperfusion therapy in out-of-hospital cardiac arrest: current insights. Resuscitation (2007) 73:189–201.[CrossRef][Web of Science][Medline]
- Li X, Fu QL, Jing XL, Li YJ, Zhan H, MA ZF, Liao XX. A meta-analysis of cardiopulmonary resuscitation with and without the administration of thrombolytic agents. Resuscitation (2006) 70:31–36.[CrossRef][Web of Science][Medline]
- Stadlbauer KH, Krismer AC, Arntz HR, Mayr VD, Lienhart HG, Bottiger BW, Jahn B, Lindner KH, Wenzel V. Effects of thrombolysis during out-of- hospital cardiopulmonary resuscitation. Am J Cardiol (2006) 97:305–308.[CrossRef][Web of Science][Medline]
- Spohr F, Wenzel V, Bottiger BW. Thrombolysis and other drugs during cardiopulmonary resuscitation. Curr Opin Crit Care (2008) 14:292–298.[CrossRef][Web of Science][Medline]
- Abu-Laban RB, Christenson JM, Innes GD, van Beek CA, Wanger KP, McKnight RD, MacPhail IA, Puskaric J, Sadowski RP, Singer J, Schechter MT, Wood VM. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med (2002) 346:1522–1528.
[Abstract/Free Full Text] - van der Wouw PA, Koster RW, Delemarre BJ, de Vos R, Lampe-Schoenmaeckers AJ, Lie KI. Diagnostic accuracy of transesophageal echocardiography during cardiopulmonary resuscitation. J Am Coll Cardiol (1997) 30:780–783.[Abstract]
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