Abstract
OBJECTIVE:
To evaluate the effects of percutaneous coronary intervention and thrombolysis after restoration of spontaneous circulation in cardiac arrest patients with ST-elevation myocardial infarction using meta-analysis.
METHODS:
We performed a meta-analysis of clinical studies indexed in the PUBMED, MEDLINE and EMBASE databases and published between January 1995 and October 2012. In addition, we compared the hospital discharge and neurological recovery rates between the patients who received percutaneous coronary intervention and those who received thrombolysis.
RESULTS:
Twenty-four studies evaluating the effects of percutaneous coronary intervention or thrombolysis after restoration of spontaneous circulation in cardiac arrest patients with ST-elevation myocardial infarction were included. Seventeen of the 24 studies were used in this meta-analysis. All studies were used to compare percutaneous coronary intervention and thrombolysis. The meta-analysis showed that the rate of hospital discharge improved with both percutaneous coronary intervention (p<0.001) and thrombolysis (p<0.001). We also found that cardiac arrest patients with ST-elevation myocardial infarction who received thrombolysis after restoration of spontaneous circulation did not have decreased hospital discharge (p = 0.543) or neurological recovery rates (p = 0.165) compared with those who received percutaneous coronary intervention.
CONCLUSION:
In cardiac arrest patients with ST-elevation myocardial infarction who achieved restoration of spontaneous circulation, both percutaneous coronary intervention and thrombolysis improved the hospital discharge rate. Furthermore, there were no significant differences in the hospital discharge and neurological recovery rates between the percutaneous coronary intervention-treated group and the thrombolysis-treated group.
Meta-analysis; Cardiac Arrest; Return of Spontaneous Circulation; St-Elevation Myocardial Infarction; Percutaneous Coronary Intervention; Thrombolysis
INTRODUCTION
Cardiac arrest (CA) is a major cause of death in adults both in and out of the hospital. The percentage of patients who survive to hospital discharge is approximately 5-10% at best (11. 2005 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 2: Adult basic life support. Resuscitation. 2005;67(2-3):187-201.). Cardiopulmonary resuscitation (CPR) is essential to prevent death and provide neuroprotection after CA. However, the hospital discharge rates following in-hospital CPR remain as low as they were 50 years ago, at 15-20% (22. Ehlenbach WJ, Barnato AE, Curtis JR, Kreuter W, Koepsell TD, Deyo RA, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;361(1):22-31.).
Epidemiological studies have shown that coronary artery disease is the primary cause of CA,
resulting in arrest within a short time due to acute myocardial infarction (AMI) or ischemia-related
arrhythmias in 56-88% of clinical cases with CA (33. Zipes DP, Wellens HJ. Sudden cardiac death. Circulation. 1998;98(21):2334-51,
http://dx.doi.org/10.1161/01.CIR.98.21.2334.
http://dx.doi.org/10.1161/01.CIR.98.21.2...
,44. Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, et al.
Immediate coronary angiography in survivors of out-of-hospital cardiac arrest.
N Engl J Med. 1997;336(23):1629-33.). Autopsy studies have demonstrated that coronary arteries
occluded by thrombi or ruptured atherosclerotic plaques have been identified in up to 95% of
patients who die from sudden cardiac death (SCD) (55. Davies MJ, Thomas A. Thrombosis and acute coronary-artery lesions in sudden
cardiac ischemic death. N Engl J Med. 1984;310(1):1137-40.,66. Myerburg RJ, Kessler KM, Estes D, Conde CA, Luceri RM, Zaman L, et al. Long-term
survival after prehospital cardiac arrest: Analysis of outcome during an 8 year study. Circulation.
1984;70(4):538-46, http://dx.doi.org/10.1161/01.CIR.70.4.538.
http://dx.doi.org/10.1161/01.CIR.70.4.53...
).
Clinical studies have shown that reperfusion therapy reduces the high mortality rate,
particularly in patients with ST-elevation myocardial infarction (STEMI) (77. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007
focused update of the acc/aha 2004 guidelines for the management of patients with st-elevation
myocardial infarction: A report of the american college of cardiology/american heart association
task force on practice guidelines. J Am Coll Cardiol. 2008;51(2):210-47,
http://dx.doi.org/10.1016/j.jacc.2007.10.001.
http://dx.doi.org/10.1016/j.jacc.2007.10...
). Some studies have demonstrated that percutaneous coronary intervention (PCI) is
beneficial in patients with STEMI (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.). Meanwhile, a meta-analysis also indicated that thrombolysis is an effective
treatment for STEMI patients (1111. Li X, Fu QL, Jing XL, Li YJ, Zhan H, Ma ZF, et al. A meta-analysis of
cardiopulmonary resuscitation with and without the administration of thrombolytic agents.
Resuscitation. 2006;70(1):31-6,
http://dx.doi.org/10.1016/j.resuscitation.2005.11.016.
http://dx.doi.org/10.1016/j.resuscitatio...
). However, a large-scale
multicenter prospective study (TROICA) indicated that thrombolysis is ineffective in patients with
CA after STEMI, and that study was stopped prematurely because of the convincing early-stage data
(1212. Bottiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, et al.
Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med.
2008;359(25:2651-62.). Therefore, the controversy still exists regarding the
efficacies of PCI and thrombolysis in patients with CA after STEMI (1212. Bottiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, et al.
Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med.
2008;359(25:2651-62.
13. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous
thrombolytic therapy for acute myocardial infarction: A quantitative review of 23 randomised trials.
Lancet. 2003;361(9351):13-20, http://dx.doi.org/10.1016/S0140-6736(03)12113-7.
http://dx.doi.org/10.1016/S0140-6736(03)...
14. Grines CL, Browne KF, Marco J, Rothbaum D, Stone GW, O'Keefe J, et al. A
comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The
primary angioplasty in myocardial infarction study group. N Engl J Med.
1993;328(10):673-9.
15. Widimsky P, Bilkova D, Penicka M, Novak M, Lanikova M, Porizka V, et al.
Long-term outcomes of patients with acute myocardial infarction presenting to hospitals without
catheterization laboratory and randomized to immediate thrombolysis or interhospital transport for
primary percutaneous coronary intervention. Five years' follow-up of the prague-2 trial. Eur
Heart J. 2007;28(6):679-84.
16. Zijlstra F, Hoorntje JC, de Boer MJ, Reiffers S, Miedema K, Ottervanger JP, et
al. Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute
myocardial infarction. N Engl J Med. 1999;341(19):1413-9.-1717. Abu-Laban RB, Christenson JM, Innes GD, van Beek CA, Wanger KP, McKnight RD, et
al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.
N Engl J Med. 2002;346(20):1522-8.).
Both PCI and thrombolysis are efficacious in patients with STEMI. However, there is a significant difference between the efficacies of PCI and thrombolysis in patients with CA after STEMI. We assumed that most studies did not distinguish the condition of patients with STEMI. Thrombolysis may be used to treat patients without return of spontaneous circulation (ROSC) after CA. Therefore, the high mortality rate of patients with CA masked the benefit of thrombolysis. However, PCI can be used to treat patients with ROSC after CA. Herein, we assessed the efficacies of PCI and thrombolysis in patients with ROSC after CA in the presence of STEMI.
METHODS
Study identification strategy
We searched for research papers indexed in the PUBMED, MEDLINE and EMBASE databases that were published from January 1995 to October 2012. The keywords used in the search were as follows: cardiac arrest or cardiopulmonary resuscitation or cardiopulmonary-cerebral resuscitation and thrombolysis or percutaneous coronary intervention and acute myocardial infarction. Furthermore, we manually reviewed the references for each article. The search was limited using the search terms “>19 years”, “Publication Date from 1995/01/01 to 2012/10/01”, “English”, “Human”, “PUBMED”, “MEDLINE” and “EMBASE”. We excluded research papers with the following keywords: “review”, “review literature”, “review of reported cases”, “review, academic”, “review, multicase”, “review, tutorial”, “case reports”, “congresses”, “interview”, “overall”, “comment”, “letter”, “practice guideline”, “scientific integrity review”, “news”, “newspaper article” and “address”. Some papers not included in the PUBMED, MEDLINE and EMBASE databases were also used in this meta-analysis.
Inclusion criteria
Eligible patients had experienced CA due to STEMI and achieved ROSC after CPR. The diagnosis of CA and whether CPR was used were determined based on the records in the respective studies. The diagnostic and management process that was followed was in accordance with the Utstein model. All the included articles were non-randomized comparative studies. Patients with ROSC after CA who then received PCI or thrombolysis treatment constituted the treatment groups. The types of PCI and the doses of thrombolytic agents used were not restricted. Patients in the control groups were those who underwent CA and achieved ROSC and who could be treated by CPR without PCI or thrombolysis. We compared the efficacies of PCI and thrombolysis between the treatment and control groups. We also compared the efficacies of PCI and thrombolysis in patients with ROSC after CA. The primary study endpoints were the rates of hospital discharge and neurological recovery.
Statistical analysis
We performed a meta-analysis using Review Manager 5.1 (The Cochrane Collaboration, Oxford, England). Odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated for each article using either the fixed-effects or the random-effects model. We used Cochran's χ2 test and the I2 test for heterogeneity to test the between-study heterogeneity, and a p<0.10 and an I2>50% were considered indicative of statistically significant heterogeneity. Between-group comparisons were performed using Pearson's χ2 test for categorical variables. All of the analyses were performed using the SPSS 17.0 software package (SPSS, Inc., Chicago, IL, USA). P-values <0.05 were considered statistically significant.
RESULTS
Eligibility of articles
In total, 127 articles were found by searching using the keywords mentioned in the methods
section. Twenty-four of these articles were cohort studies and involved CA patients with STEMI who
were treated with or without PCI or thrombolysis after ROSC. One hundred three articles were
excluded because: they were reviews, case reports, or letters; they reported findings for CA patients with
pulmonary embolisms (PEs) or for CA patients who had received reperfusion therapy during CPR without
ROSC; or the
authors of the study did not present the details regarding the hospital discharge and neurological
recovery rates. Because controlled studies are necessary for meta-analyses, the 17 cohort-controlled
studies (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
23. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
24. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
25. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
26. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.
27. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
28. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
29. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
30. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.-3131. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
) were included our the
meta-analysis to assess the efficacies of PCI and thrombolysis in patients with ROSC after CA.
Fifteen studies (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
23. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
24. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
25. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
26. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.
27. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
28. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
-2929. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
) out
of the total were used to analyze the efficacy of PCI. Four studies (2626. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.,2727. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
,3030. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.,3131. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
) were used to analyze the efficacy of thrombolysis. After the
meta-analysis, we used all 24 studies (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
23. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
24. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
25. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
26. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.
27. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
28. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
29. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
30. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.
31. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
32. Arntz HR, Wenzel V, Dissmann R, Marschalk A, Breckwoldt J, Muller D.
Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood
of st-elevation myocardial infarction. Resuscitation. 2008;76(2):180-4,
http://dx.doi.org/10.1016/j.resuscitation.2007.07.012.
http://dx.doi.org/10.1016/j.resuscitatio...
33. Bendz B, Eritsland J, Nakstad AR, Brekke M, Klow NE, Steen PA, et al. Long-term
prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention.
Resuscitation. 2004;63(1):49-53,
http://dx.doi.org/10.1016/j.resuscitation.2004.04.006.
http://dx.doi.org/10.1016/j.resuscitatio...
34. Keelan PC, Bunch TJ, White RD, Packer DL, Holmes DR, Jr. Early direct coronary
angioplasty in survivors of out-of-hospital cardiac arrest. Am J Cardiol.
2003;91(12):1461-3, http://dx.doi.org/10.1016/S0002-9149(03)00398-9.
http://dx.doi.org/10.1016/S0002-9149(03)...
35. Knafelj R, Radsel P, Ploj T, Noc M. Primary percutaneous coronary intervention
and mild induced hypothermia in comatose survivors of ventricular fibrillation with st-elevation
acute myocardial infarction. Resuscitation. 2007;74(2):227-34,
http://dx.doi.org/10.1016/j.resuscitation.2007.01.016.
http://dx.doi.org/10.1016/j.resuscitatio...
36. Mager A, Kornowski R, Murninkas D, Vaknin-Assa H, Ukabi S, Brosh D, et al.
Outcome of emergency percutaneous coronary intervention for acute st-elevation myocardial infarction
complicated by cardiac arrest. Coron Artery Dis. 2008;19(8):615-8,
http://dx.doi.org/10.1097/MCA.0b013e32831381b4.
http://dx.doi.org/10.1097/MCA.0b013e3283...
37. Marcusohn E, Roguin A, Sebbag A, Aronson D, Dragu R, Amikam S, et al. Primary
percutaneous coronary intervention after out-of-hospital cardiac arrest: Patients and outcomes. Isr
Med Assoc J. 2007;9(4):257-9.-3838. Valente S, Lazzeri C, Saletti E, Chiostri M, Gensini GF. Primary percutaneous
coronary intervention in comatose survivors of cardiac arrest with st-elevation acute myocardial
infarction: A single-center experience in florence. J Cardiovasc Med (Hagerstown).
2008;9(11):1083-7, http://dx.doi.org/10.2459/JCM.0b013e3282ff82d4.
http://dx.doi.org/10.2459/JCM.0b013e3282...
) to compare the hospital discharge and neurological recovery rates between the
PCI and thrombolysis groups among patients with ROSC after CA. The main features of these selected
cohort studies are listed in Table 1.
Comparison of the hospital discharge rate between with- and without-PCI patients with ROSC after CA
We first compared the rate of hospital discharge between the with- and without-PCI patient groups
using data from 15 articles (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
23. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
24. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
25. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
26. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.
27. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
28. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
-2929. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
). Overall, 1320 patients had ROSC after CA and then received PCI treatment. A total of
860 (65.15%, 95%CI, 62.58-67.72) of these patients survived to hospital discharge. In addition, 2152
patients with ROSC after CA did not receive PCI, and 1017 (47.26%, 95%CI, 45.15-49.37) of these
patients were discharged from the hospital. In this meta-analysis, we used a random-effects model to
take into account the effect of heterogeneity among studies (Tau2 = 0.33;
χ2 = 54.25; p<0.00001; I2 = 74%). This meta-analysis
indicated that PCI significantly improved the rate of hospital discharge in patients with ROSC after
CA (OR, 1.92; 95% CI, 1.32-2.78, p<0.001) (Figure 1).
Forest plot of the hospital discharge rates between the with- and without-PCI patients for the meta-analysis.
Comparison of neurological recovery between with- and without-PCI patients with ROSC after CA
We also compared the neurological recovery rate between the with- and without-PCI groups using
data from 12 articles (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
-2323. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
,2525. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
,2626. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.,2828. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
). Neurological recovery was described and recorded using the Cerebral
Performance Categories (CPC) scale. Neurological recovery was considered good for patients who could
perform their normal activities independently (CPC 1 or 2). Neurological recovery was considered
bad, poor or unfavorable for patients who were dependent on others, who were vegetative or who had
died (CPC 3, 4 or 5).
The authors assessed the CPC score at the time of hospital discharge. The rates of good neurological recovery were 95.03% (726 of 764 patients; 95%CI, 93.49-96.57) and 78.10% (724 of 927 patients; 95%CI, 75.44-80.76) for the with- or without-PCI patient groups, respectively. To reduce the heterogeneity among these studies (Tau2 = 0.86; χ2 = 26.40; p = 0.006; I2 = 58%), we used a random-effects model. PCI treatment significantly improved the rate of neurological recovery at the time of hospital discharge in patients with ROSC after CA (OR, 6.71; 95% CI, 2.97-15.15, p<0.001) (Figure 2).
Forest plot of the neurological recovery rates between the with- and without-PCI patients for the meta-analysis.
Comparison of the hospital discharge rate between with- and without-thrombolysis patients with ROSC after CA
We also compared the rate of hospital discharge between the with- and without-thrombolysis
patient groups using data from four articles (2626. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.,2727. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
,3030. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.,3131. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
). Thrombolysis was performed in 217 patients with ROSC after CA, and 158
(72.81%, 95%CI, 66.89-78.73) of these patients survived to hospital discharge. In addition, 462
patients with ROSC after CA were not treated with thrombolysis, and 238 (51.52%, 95%CI, 49.96-56.08)
of these patients survived to hospital discharge. A fixed-effects model was used in this
meta-analysis to account for the lack of heterogeneity among the included studies
(χ2 = 2.87, p = 0.41, I2 = 0%), and the analysis indicated
that thrombolysis could also significantly improve the rate of hospital discharge in patients with
ROSC after CA (OR, 2.63, 95%CI, 1.77-3.90, p<0.001) (Figure 3).
Forest plot of the hospital discharge rates between the with- and without-thrombolysis patients for the meta-analysis.
Comparison of neurological recovery between with- and without-thrombolysis patients with ROSC after CA
To compare the neurological recovery between the with- and without-thrombolysis patient groups,
data from two articles were analyzed (2626. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.,3131. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
). The CPC scale was used. The homogeneity of the two studies was
good (χ2 = 1.17, p = 0.28, I2 = 15%). Therefore, we used a
fix-effects model for this meta-analysis. Overall, 86.00% (86 of 100 patients; 95% CI, 82.53-89.47)
and 90.80% (79 of 87 patients; 95% CI, 84.73-96.87) of patients had a good neurological recovery in
the patient groups with and without thrombolysis, respectively. Thrombolysis did not improve the
neurological recovery status at the time of hospital discharge in patients with ROSC after CA (OR,
0.76, 95%CI, 0.27-2.17, p = 0.309) (Figure 4).
Forest plot of the neurological recovery rates between the with- and without-thrombolysis patients for the meta-analysis.
Comparison of the hospital discharge rate between the PCI and thrombolysis groups among patients with ROSC after CA
There were 24 articles included in this comparison of the PCI and thrombolysis treatment groups.
There were 21 articles (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
23. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
24. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
25. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
26. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.
27. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
28. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
-2929. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
) on
PCI and 5 articles (2626. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.,2727. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
,3030. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.
31. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
-3232. Arntz HR, Wenzel V, Dissmann R, Marschalk A, Breckwoldt J, Muller D.
Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood
of st-elevation myocardial infarction. Resuscitation. 2008;76(2):180-4,
http://dx.doi.org/10.1016/j.resuscitation.2007.07.012.
http://dx.doi.org/10.1016/j.resuscitatio...
) on
thrombolysis. Among the patients included in this analysis, 65.88% (1004 of 1524 patients, 95%CI,
63.50-68.26) survived to hospital discharge in the PCI treatment group. Similarly, 67.79% (181 of
267 patients, 95%CI, 62.18-73.40) of patients in the thrombolysis treatment group survived to
hospital discharge. We found that the prognosis of patients treated with PCI was no better than that
of patients treated with thrombolysis with respect to the hospital discharge rates
(p = 0.543, Figure 5).
Comparison of the hospital discharge and neurological recovery rates between the PCI and thrombolysis groups Left: Comparison of the hospital discharge rates between the PCI and thrombolysis groups (p = 0.543) Right: Comparison of the neurological recovery rates between the PCI and thrombolysis groups (p = 0.165).
Comparison of neurological recovery between the PCI and thrombolysis groups among patients with ROSC after CA
This comparison between the PCI and thrombolysis groups was performed using 18 articles. There
were 16 articles (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
-2323. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
,2525. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
,2626. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.,2828. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
,3434. Keelan PC, Bunch TJ, White RD, Packer DL, Holmes DR, Jr. Early direct coronary
angioplasty in survivors of out-of-hospital cardiac arrest. Am J Cardiol.
2003;91(12):1461-3, http://dx.doi.org/10.1016/S0002-9149(03)00398-9.
http://dx.doi.org/10.1016/S0002-9149(03)...
35. Knafelj R, Radsel P, Ploj T, Noc M. Primary percutaneous coronary intervention
and mild induced hypothermia in comatose survivors of ventricular fibrillation with st-elevation
acute myocardial infarction. Resuscitation. 2007;74(2):227-34,
http://dx.doi.org/10.1016/j.resuscitation.2007.01.016.
http://dx.doi.org/10.1016/j.resuscitatio...
36. Mager A, Kornowski R, Murninkas D, Vaknin-Assa H, Ukabi S, Brosh D, et al.
Outcome of emergency percutaneous coronary intervention for acute st-elevation myocardial infarction
complicated by cardiac arrest. Coron Artery Dis. 2008;19(8):615-8,
http://dx.doi.org/10.1097/MCA.0b013e32831381b4.
http://dx.doi.org/10.1097/MCA.0b013e3283...
-3737. Marcusohn E, Roguin A, Sebbag A, Aronson D, Dragu R, Amikam S, et al. Primary
percutaneous coronary intervention after out-of-hospital cardiac arrest: Patients and outcomes. Isr
Med Assoc J. 2007;9(4):257-9.) on PCI and 3 articles (2626. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.,3131. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
,3232. Arntz HR, Wenzel V, Dissmann R, Marschalk A, Breckwoldt J, Muller D.
Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood
of st-elevation myocardial infarction. Resuscitation. 2008;76(2):180-4,
http://dx.doi.org/10.1016/j.resuscitation.2007.07.012.
http://dx.doi.org/10.1016/j.resuscitatio...
) on thrombolysis. Among the patients
included in this analysis, 856 patients with ROSC after CA who received PCI survived to hospital
discharge, and 790 (92.29%, 95%CI, 90.50-94.08) patients had a good neurological recovery. In
addition, 123 patients with ROSC after CA were treated with thrombolysis and survived to hospital
discharge, and 109 (88.62%, 95%CI, 83.01-94.23) patients had good neurological recovery. We noted
that the PCI treatment group did not have a significantly better neurological recovery rate than the
thrombolysis treatment group among patients with ROSC after CA (p = 0.165, Figure 5.
Comparison of the hospital discharge and neurological recovery rates in patients with ROSC after in-hospital CA (IHCA) or out-of-hospital CA (OHCA)
Even after excluding studies involving IHCA (2020. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
,2121. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
,2424. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
,2929. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
,3030. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.,3636. Mager A, Kornowski R, Murninkas D, Vaknin-Assa H, Ukabi S, Brosh D, et al.
Outcome of emergency percutaneous coronary intervention for acute st-elevation myocardial infarction
complicated by cardiac arrest. Coron Artery Dis. 2008;19(8):615-8,
http://dx.doi.org/10.1097/MCA.0b013e32831381b4.
http://dx.doi.org/10.1097/MCA.0b013e3283...
), results similar to those described above were obtained. Thus, PCI and thrombolysis had
the same level of efficacy in patients with ROSC whether they experienced IHCA or OHCA.
DISCUSSION
Based on the 17 included studies (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
23. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
24. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
25. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
26. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.
27. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
28. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
29. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
30. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.-3131. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
), the meta-analysis indicated that both PCI and thrombolysis could improve the hospital
discharge rate for patients with ROSC after CA, but only PCI could improve the neurological recovery
rate. However, further analysis using a total of 24 studies (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.,1818. Anyfantakis ZA, Baron G, Aubry P, Himbert D, Feldman LJ, Juliard JM, et al.
Acute coronary angiographic findings in survivors of out-of-hospital cardiac arrest. Am
Heart J. 2009;157(2):312-8, http://dx.doi.org/10.1016/j.ahj.2008.09.016.
http://dx.doi.org/10.1016/j.ahj.2008.09....
19. Cronier P, Vignon P, Bouferrache K, Aegerter P, Charron C, Templier F, et al.
Impact of routine percutaneous coronary intervention after out-of-hospital cardiac arrest due to
ventricular fibrillation. Crit Care. 2011;15(3):R122,
http://dx.doi.org/10.1186/cc10227.
http://dx.doi.org/10.1186/cc10227...
20. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
21. Hosmane VR, Mustafa NG, Reddy VK, Reese CLt, DiSabatino A, Kolm P, et al.
Survival and neurologic recovery in patients with st-segment elevation myocardial infarction
resuscitated from cardiac arrest. J Am Coll Cardiol. 2009;53(5):409-15,
http://dx.doi.org/10.1016/j.jacc.2008.08.076.
http://dx.doi.org/10.1016/j.jacc.2008.08...
22. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
23. Lettieri C, Savonitto S, De Servi S, Guagliumi G, Belli G, Repetto A, et al.
Emergency percutaneous coronary intervention in patients with st-elevation myocardial infarction
complicated by out-of-hospital cardiac arrest: Early and medium-term outcome. Am Heart J.
2009;157(3):569-75, http://dx.doi.org/10.1016/j.ahj.2008.10.018.
http://dx.doi.org/10.1016/j.ahj.2008.10....
24. Merchant RM, Abella BS, Khan M, Huang KN, Beiser DG, Neumar RW, et al. Cardiac
catheterization is underutilized after in-hospital cardiac arrest. Resuscitation.
2008;79(3):398-403, http://dx.doi.org/10.1016/j.resuscitation.2008.07.015.
http://dx.doi.org/10.1016/j.resuscitatio...
25. Pleskot M, Babu A, Hazukova R, Stritecky J, Bis J, Matejka J, et al.
Out-of-hospital cardiac arrests in patients with acute st elevation myocardial infarctions in the
east bohemian region over the period 2002-2004. Cardiology.2008;109(1):41-51,
http://dx.doi.org/10.1159/000105325.
http://dx.doi.org/10.1159/000105325...
26. Richling N, Herkner H, Holzer M, Riedmueller E, Sterz F, Schreiber W.
Thrombolytic therapy vs primary percutaneous intervention after ventricular fibrillation cardiac
arrest due to acute st-segment elevation myocardial infarction and its effect on outcome.
Am J Emerg Med. 2007;25(5):545-50.
27. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
28. Tomte O, Andersen GO, Jacobsen D, Draegni T, Auestad B, Sunde K. Strong and weak
aspects of an established post-resuscitation treatment protocol-a five-year observational study.
Resuscitation. 2011;82(9):1186-93,
http://dx.doi.org/10.1016/j.resuscitation.2011.05.003.
http://dx.doi.org/10.1016/j.resuscitatio...
29. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
30. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.
31. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
32. Arntz HR, Wenzel V, Dissmann R, Marschalk A, Breckwoldt J, Muller D.
Out-of-hospital thrombolysis during cardiopulmonary resuscitation in patients with high likelihood
of st-elevation myocardial infarction. Resuscitation. 2008;76(2):180-4,
http://dx.doi.org/10.1016/j.resuscitation.2007.07.012.
http://dx.doi.org/10.1016/j.resuscitatio...
33. Bendz B, Eritsland J, Nakstad AR, Brekke M, Klow NE, Steen PA, et al. Long-term
prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention.
Resuscitation. 2004;63(1):49-53,
http://dx.doi.org/10.1016/j.resuscitation.2004.04.006.
http://dx.doi.org/10.1016/j.resuscitatio...
34. Keelan PC, Bunch TJ, White RD, Packer DL, Holmes DR, Jr. Early direct coronary
angioplasty in survivors of out-of-hospital cardiac arrest. Am J Cardiol.
2003;91(12):1461-3, http://dx.doi.org/10.1016/S0002-9149(03)00398-9.
http://dx.doi.org/10.1016/S0002-9149(03)...
35. Knafelj R, Radsel P, Ploj T, Noc M. Primary percutaneous coronary intervention
and mild induced hypothermia in comatose survivors of ventricular fibrillation with st-elevation
acute myocardial infarction. Resuscitation. 2007;74(2):227-34,
http://dx.doi.org/10.1016/j.resuscitation.2007.01.016.
http://dx.doi.org/10.1016/j.resuscitatio...
36. Mager A, Kornowski R, Murninkas D, Vaknin-Assa H, Ukabi S, Brosh D, et al.
Outcome of emergency percutaneous coronary intervention for acute st-elevation myocardial infarction
complicated by cardiac arrest. Coron Artery Dis. 2008;19(8):615-8,
http://dx.doi.org/10.1097/MCA.0b013e32831381b4.
http://dx.doi.org/10.1097/MCA.0b013e3283...
37. Marcusohn E, Roguin A, Sebbag A, Aronson D, Dragu R, Amikam S, et al. Primary
percutaneous coronary intervention after out-of-hospital cardiac arrest: Patients and outcomes. Isr
Med Assoc J. 2007;9(4):257-9.-3838. Valente S, Lazzeri C, Saletti E, Chiostri M, Gensini GF. Primary percutaneous
coronary intervention in comatose survivors of cardiac arrest with st-elevation acute myocardial
infarction: A single-center experience in florence. J Cardiovasc Med (Hagerstown).
2008;9(11):1083-7, http://dx.doi.org/10.2459/JCM.0b013e3282ff82d4.
http://dx.doi.org/10.2459/JCM.0b013e3282...
) indicated that there were not significant differences in the
hospital discharge and neurological recovery rates between the PCI and thrombolysis treatment
groups.
PCI and thrombolysis are the two main reperfusion strategies currently in use. According to the
recent AHA guidelines concerning CPR for ACS (acute coronary syndrome) patients (3939. O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, et al.
Acute Coronary Syndrome Chapter Collaborators. Circulation. 2010;122(16 Suppl 2):S422-65,
http://dx.doi.org/10.1161/CIRCULATIONAHA.110.985549.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
), PCI may be considered for patients with ROSC after CA. Our
data indicate that such a strategy improved the rate of hospital discharge and enhanced neurological
recovery in patients with ROSC following CA. However, the efficacy of thrombolysis has been rarely
mentioned in regard to CA patients. A recent randomized study (TROICA) reported that thrombolysis
did not improve the hospital discharge and neurological recovery rates in patients with CA. The
TROICA researchers reported that one possible reason might be the administration of antithrombin and
antiplatelet agents during CPR. Another important reason might be the restriction of the perfusion
of vital organs during CPR by blood clots in the coronary arteries, limiting the perfusion pressure
and hindering the delivery of the thrombolytic agents to the location where they were to play their
thrombolytic role (1212. Bottiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, et al.
Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med.
2008;359(25:2651-62.). We concluded that one main possible
reason for the lack of efficacy for thrombolysis might have been the lack of distinguishing patients
with ROSC after CA from those without ROSC; when CA patients achieve ROSC, there may be suitable
perfusion pressure in the coronary arteries, allowing thrombolysis could function effectively. In
this study, we studied the efficacies of thrombolysis and PCI in patients with ROSC after CA, and we
identified no differences in the hospital discharge and neurological recovery rates.
Plaque rupture, thrombus collapse and embolisms play key roles in the pathogenesis of SCD (55. Davies MJ, Thomas A. Thrombosis and acute coronary-artery lesions in sudden
cardiac ischemic death. N Engl J Med. 1984;310(1):1137-40.,66. Myerburg RJ, Kessler KM, Estes D, Conde CA, Luceri RM, Zaman L, et al. Long-term
survival after prehospital cardiac arrest: Analysis of outcome during an 8 year study. Circulation.
1984;70(4):538-46, http://dx.doi.org/10.1161/01.CIR.70.4.538.
http://dx.doi.org/10.1161/01.CIR.70.4.53...
). Clinical studies have
already identified disrupted atherosclerotic plaques or occlusive thrombi in CA survivors using
coronary angiography (44. Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, et al.
Immediate coronary angiography in survivors of out-of-hospital cardiac arrest.
N Engl J Med. 1997;336(23):1629-33.). Therefore, early reperfusion
therapy in patients with STEMI is an important cornerstone of the recommended therapy and is also
recommended by the European Society of Cardiology (ESC) (4040. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al.
Management of acute myocardial infarction in patients presenting with persistent st-segment
elevation: The task force on the management of st-segment elevation acute myocardial infarction of
the european society of cardiology. Eur Heart J. 2008;29(23):2909-45.).
Reperfusion treatment has been used to treat AMI patients for the past 20 years. As the two main
reperfusion approaches for AMI, PCI and thrombolysis can recanalize the occluded artery, reduce the
infarct size, minimize myocardial damage, enhanced left ventricular recovery, reduce the incidence
of arrhythmias and decrease mortality (1313. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous
thrombolytic therapy for acute myocardial infarction: A quantitative review of 23 randomised trials.
Lancet. 2003;361(9351):13-20, http://dx.doi.org/10.1016/S0140-6736(03)12113-7.
http://dx.doi.org/10.1016/S0140-6736(03)...
). Because AMI is
the main underlying cause of CA (33. Zipes DP, Wellens HJ. Sudden cardiac death. Circulation. 1998;98(21):2334-51,
http://dx.doi.org/10.1161/01.CIR.98.21.2334.
http://dx.doi.org/10.1161/01.CIR.98.21.2...
,44. Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, et al.
Immediate coronary angiography in survivors of out-of-hospital cardiac arrest.
N Engl J Med. 1997;336(23):1629-33.), therapeutic strategies for coronary reperfusion should be equally appropriate
for CA patients. However, in clinical practice, there is still some controversy concerning the roles
and efficacies of PCI and thrombolysis for the treatment of patients with CA caused by AMI (44. Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, et al.
Immediate coronary angiography in survivors of out-of-hospital cardiac arrest.
N Engl J Med. 1997;336(23):1629-33.,1212. Bottiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, et al.
Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med.
2008;359(25:2651-62.,1717. Abu-Laban RB, Christenson JM, Innes GD, van Beek CA, Wanger KP, McKnight RD, et
al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.
N Engl J Med. 2002;346(20):1522-8.,2020. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
,2222. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
).
PCI can directly open the occluded coronary artery and stabilize hemodynamics. Many clinical
studies on reperfusion therapy have indicated that immediate PCI after CA is a safe procedure and is
associated with a good prognosis (44. Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, et al.
Immediate coronary angiography in survivors of out-of-hospital cardiac arrest.
N Engl J Med. 1997;336(23):1629-33.,88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
,2020. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
,2222. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
,2727. Bulut S, Aengevaeren WR, Luijten HJ, Verheugt FW. Successful out-of-hospital
cardiopulmonary resuscitation: What is the optimal in-hospital treatment strategy? Resuscitation.
2000;47(2):155-61, http://dx.doi.org/10.1016/S0300-9572(00)00217-3.
http://dx.doi.org/10.1016/S0300-9572(00)...
,2929. Gorjup V, Radsel P, Kocjancic ST, Erzen D, Noc M. Acute st-elevation myocardial
infarction after successful cardiopulmonary resuscitation. Resuscitation. 2007;72(3):379-85,
http://dx.doi.org/10.1016/j.resuscitation.2006.07.013.
http://dx.doi.org/10.1016/j.resuscitatio...
,3333. Bendz B, Eritsland J, Nakstad AR, Brekke M, Klow NE, Steen PA, et al. Long-term
prognosis after out-of-hospital cardiac arrest and primary percutaneous coronary intervention.
Resuscitation. 2004;63(1):49-53,
http://dx.doi.org/10.1016/j.resuscitation.2004.04.006.
http://dx.doi.org/10.1016/j.resuscitatio...
,3737. Marcusohn E, Roguin A, Sebbag A, Aronson D, Dragu R, Amikam S, et al. Primary
percutaneous coronary intervention after out-of-hospital cardiac arrest: Patients and outcomes. Isr
Med Assoc J. 2007;9(4):257-9.). A series of
large-scale clinical studies demonstrated that PCI has pronounced efficacy for treating CA patients
with STEMI (88. Dumas F, Cariou A, Manzo-Silberman S, Grimaldi D, Vivien B, Rosencher J, et al.
Immediate percutaneous coronary intervention is associated with better survival after
out-of-hospital cardiac arrest: Insights from the procat (parisian region out of hospital cardiac
arrest) registry. Circ Cardiovasc Interv. 2010;3(3):200-7,
http://dx.doi.org/10.1161/CIRCINTERVENTIONS.109.913665.
http://dx.doi.org/10.1161/CIRCINTERVENTI...
9. Koeth O, Zahn R, Bauer T, Juenger C, Gitt AK, Senges J, et al. Primary
percutaneous coronary intervention and thrombolysis improve survival in patients with st-elevation
myocardial infarction and pre-hospital resuscitation. Resuscitation. 2010;81(11):1505-8,
http://dx.doi.org/10.1016/j.resuscitation.2010.06.018.
http://dx.doi.org/10.1016/j.resuscitatio...
-1010. Nielsen N, Hovdenes J, Nilsson F, Rubertsson S, Stammet P, Sunde K, et al.
Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrest.
Acta Anaesthesiol Scand 2009;53(7):926-34.), a
result that was confirmed by our meta-analysis. We know that thrombolysis is able to improve the
prognosis of STEMI patients and has an efficacy comparable to that of PCI. However, it is not clear
why there is such a large difference between these treatments in CA patients. After carefully
analyzing the relevant articles (4,4. Spaulding CM, Joly LM, Rosenberg A, Monchi M, Weber SN, Dhainaut JF, et al.
Immediate coronary angiography in survivors of out-of-hospital cardiac arrest.
N Engl J Med. 1997;336(23):1629-33.,1212. Bottiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, et al.
Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med.
2008;359(25:2651-62.,1717. Abu-Laban RB, Christenson JM, Innes GD, van Beek CA, Wanger KP, McKnight RD, et
al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.
N Engl J Med. 2002;346(20):1522-8.,2020. Garot P, Lefevre T, Eltchaninoff H, Morice MC, Tamion F, Abry B, et al.
Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after
cardiac arrest complicating st-elevation myocardial infarction. Circulation. 2007;115(11):1354-62,
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.657619.
http://dx.doi.org/10.1161/CIRCULATIONAHA...
,2222. Kahn JK, Glazier S, Swor R, Savas V, O'Neill WW. Primary coronary angioplasty
for acute myocardial infarction complicated by out-of-hospital cardiac arrest.
Am J Cardiol. 1995;75(15):1069-70,
http://dx.doi.org/10.1016/S0002-9149(99)80727-9.
http://dx.doi.org/10.1016/S0002-9149(99)...
), we found that this difference may be the
result of the selection of the study populations. PCI was used to treat patients with STEMI without
CA. In contrast, thrombolysis was most often used to treat patients with STEMI with CA because of
its convenience and rapid action. The high mortality rate of CA patients masked the benefit of
thrombolysis for the treatment of AMI (4141. Sasson C, Hegg AJ, Macy M, Park A, Kellermann A, McNally B. Prehospital
termination of resuscitation in cases of refractory out-of-hospital cardiac arrest. JAMA.
2008;300(12):1432-8, http://dx.doi.org/10.1001/jama.300.12.1432.
http://dx.doi.org/10.1001/jama.300.12.14...
42. Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, et al. Advanced
cardiac life support in out-of-hospital cardiac arrest. N Engl J Med
2004;351(7):647-56.-4343. Gueugniaud PY, David JS, Chanzy E, Hubert H, Dubien PY, Mauriaucourt P, et al.
Vasopressin and epinephrine vs. Epinephrine alone in cardiopulmonary
resuscitation. N Engl J Med. 2008;359(1):21-30.). With the development of CPR, medical scientists have realized
the importance of neuroprotection after CPR, especially in patients with ROSC after CA. Our
meta-analysis and comparative analysis aimed to evaluate the benefits of PCI and thrombolysis for
patients with ROSC after CA.
In this study, we found that both PCI and thrombolysis improved the hospital discharge rates of
patients with ROSC after CA. There were no significant differences in the hospital discharge and
neurological recovery rates of CA patients. We also found that thrombolysis could improve the
hospital discharge rate, but it could not improve the neurological recovery rate. However, several
studies have demonstrated that thrombolysis also results in good neurological recovery in CA
patients. Hemodynamic studies indicate that thrombolysis can decrease microthrombosis, improve
microcirculation metabolism and further promote neurological recovery (3030. Ruiz-Bailen M, Aguayo de Hoyos E, Serrano-Corcoles MC, Diaz-Castellanos MA,
Ramos-Cuadra JA, Reina-Toral A. Efficacy of thrombolysis in patients with acute myocardial
infarction requiring cardiopulmonary resuscitation. Intensive Care Med.
2001;27(6):1050-7.,3131. Schreiber W, Gabriel D, Sterz F, Muellner M, Kuerkciyan I, Holzer M, et al.
Thrombolytic therapy after cardiac arrest and its effect on neurological outcome. Resuscitation.
2002;52(1):63-9, http://dx.doi.org/10.1016/S0300-9572(01)00432-4.
http://dx.doi.org/10.1016/S0300-9572(01)...
). Therefore, we concluded that the
previous studies are insufficient to demonstrate the benefit of thrombolysis in neurological
recovery.
Reperfusion therapy can open the occluded artery and rescue dying myocardium in patients with
ROSC after CA. PCI is used to treat patients with STEMI but without CA, preventing many deaths.
Thrombolysis is used to treat patients with STEMI during CPR. However, patient hemodynamics are
unstable during that time. This instability may be the reason why the results were so dismal. Our
results indicate that the first step should be the selection of patients with ROSC after CA; then,
the decision between PCI and thrombolysis can be made. In developing countries, the mortality rate
for ischemic heart disease is expected to increase by almost 120-137%, compared with 29-48% in
developed countries, between 1990 and 2020; however, developing countries cannot afford the widely
used expensive PCI techniques (4444. Yusuf S, Reddy S, Ounpuu S, Anand S. Global Burden of Cardiovascular
DiseasesPart I: General Considerations, the Epidemiologic Transition, Risk Factors, and Impact of
Urbanization. Circulation. 2001;104(22):2746-53,
http://dx.doi.org/10.1161/hc4601.099487.
http://dx.doi.org/10.1161/hc4601.099487...
,4545. Jafary FH, Ahmed H, Kiani J. Outcomes of primary percutaneous coronary
intervention at a joint commission international accredited hospital in a developing country -- can
good results, possibly similar to the west, be achieved? J Invasive Cardiol.
2007;19(10):417-23.). Compared with PCI, thrombolysis is convenient and rapid, has a similar
efficacy and is relatively simple, making it especially suited for use in clinics that cannot
perform PCI. Our findings provide information to guide the resuscitation of patients with ROSC after
CA. Of course, these results require validation by additional randomized control trials.
In conclusion, our comparative analysis demonstrated that thrombolysis had an efficacy similar to that of PCI in patients with ROSC after CA. Our results indicate that there is still a need to conduct large-scale randomized clinical trials to confirm the benefits of thrombolysis in patients with ROSC after CA and in the presence of STEMI.
This study was supported by funding from the National Natural Science Foundation of China (NSFC) (81272062, 81071030), the Science and Technology Foundation of Guangdong Province, China (2010B031600089, 2011B080701006) and the Training Foundation for the Youth Scholars of Sun Yat-sen University (09ykpy31). The funders had no role in the study design, data collection, analysis, decision to publish or preparation of the manuscript.
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No potential conflict of interest was reported.
Publication Dates
-
Publication in this collection
Apr 2013
History
-
Received
10 Nov 2012 -
Reviewed
5 Dec 2012 -
Accepted
26 Dec 2012