Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation: a perspective clinical trial

Background During cardiopulmonary resuscitation (CPR), thrombolysis can hel p to stabilise patients with pulmonary embolism and myocardial infarction. Moreover, thrombolysis during CPR has beneficial effects on cerebral reperf usion after cardiac arrest. We investigated this new therapeutic approach i n patients in whom conventional CPR had been unsuccessful. Methods We assessed, in a prospective study, patients undergoing CPR after out-of-hospital cardiac arrest for cardiological reasons in whom return of spontaneous circulation was not achieved within 15 min. According to the Us tein criteria, our control group consisted of patients who were assessed du ring 1 year. After this year patients were treated with a bolus of 5000 U o f heparin and 50mg, over 2 min, of tissue-type plasminogen activator (rt-PA treated group). This intervention was repeated if return of spontaneous ci rculation was not achieved within the following 30 min. For controls only C PR was given. Findings Overall, 90 patients were included; heparin and rt-PA were given t o 40 patients. There were no bleeding complications related to the CPR proc edures. Of the rt-PA group, 68% (27) had return of spontaneous circulation and 58% (23) were admitted to a cardiac intensive care unit, compared with 44% (22; p=0.026) and 30% (15; p=0.009) of the controls, respectively. At 2 4 h after cardiac arrest a larger proportion of the rt-PA group than of the controls was alive (35% [14] vs 22% [11], p=0.171), and 15% (six) of rt-PA -treated patients and 8% (four) of controls could be discharged from hospit al. Interpretation After initially unsuccessful out-of-hospital CPR, thrombolyt ic therapy combined with heparin is safe and might improve patient outcome. On the basis of our data a randomised controlled trial might be regarded a s ethical.