Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction

Frequency of Complications of Cardiopulmonary Resuscitation After Thrombolysis During Acute Myocardial Infarction Karl H. Scholz, MD, Ulrich Tebbe, MD, Christoph Herrmann, MD, Jaroslav Wojcik, MD, Renate Lingen, MD, Joerg M. Chemnitius, MD, Stephan Brune, MD, and Heinrich Kreuzer, MD Proionged external cardiac massage is often regarded as a contraindication for thromboiytic therapy because of the risk of fatal hemorrhage. The influence of cardiopulmonary resuscitation on complications of thromboiytic bleeding was assessed analyzing data of ail patients with myocardial infarction admitted to our clinic during the lo-year period between 1978 and 1987. From the total of 2,147 patients with acute myocardiai infarction, 590 received thromboiytic therapy (intracoronary in 229, intravenous in 400). Of these, 43 patients underwent prolonged cardiopuimonary resuscitation and received thromboiysis within a time interval of <24 hours. in 21 patients, resuscitation was performed within a short period of time (5 minutes to 20 hours) after thromboiysis (10 intracoronary, 10 intravenous, 1 intravenous + intracoronary) had been initiated; 9 of these patients survived (43%). in the other 22 patients, thromboiytic therapy was initiated during ongoing resuscitation (n = 6: intravenous in 5, intravenous + intracoronary in 1) or in the early phase (10 to 120 minutes) after successful resuscitation (n = 16: intracoronary in 10, intravenous in 4, intravenous + intracoronary in 2). From this group, 14 patients survived (in-hospital mortality 36%). The mean duration of cardiopulmonary resuscitation was 36 f 32 minutes (range 4 to 120). Autopsy studies were performed in 16 of 20 deceased patients. Bleeding compiications occurred in 8 of 43 patients. No case of bleeding was directly related to cardhompression despite the often traumatic procedure with rib fractures verified in 17 patients. There was no difference in the rate of bleeding complications for patients with (n = 43) and without (n = 547) resuscitation (18.6 VI 16.1%; chi-square = 0.34, p = not significant). Thus, in patients with acute myocardiai infarction, precedtng or ongoing external cardiac massage, per se, should not be regarded as contraindication for thromboiytic therapy. (Am J Cardioi 1992;69:724-728)

ccording to exclusioncriteria in mostof the major studies on thrombolysis in acute myocardial infarction-8 preceding cardiopulmonary resuscitation is generally regarded as contraindication for this causal and effective therapy. However, with the excep tion of few case reports,9,10no data to date are available regarding the rate of bleeding complications using thrombolysis in connection with prolonged resuscitation in myocardial infarction. This investigation assesses the influence of mechanicalresuscitation performed either a short time before, during or after initiation of thrombolytic therapy on the rate of bleeding complications in a group of patients with myocardial infarction.

A

MfSHOD6 Pattent population: In a previous study investigating

the effectsof acute coronary interventions on mortality, we analyzedclinical data of all patients with myocardial infarction admitted to our hospital between January 1978 and December 1987. From a total of 5,940 registered patients presentingat our emergencyward or coronary care units with chest pain, arrhythmias, resuscitation or any other events that possibly could have been related to myocardial infarction, the diagnosisof acute myocardial infarction had been verified in 2,147 patients on the basis of 22 of the following criteria”: severe angina1 chest pain, infarct-specific electrocardiographic changesin L2 contiguous leads (ST elevation >O.l mV in standard leads and >0.2 mV in precordial leads), increase of creatine kinase activity to at least threefold of normal (>200 U/liter) with a ratio of creatine kinase-MB fraction of 16%, or alternatively by autopsy findings. Thromboiytii therapy: All patients with acute myocardial infarction received intravenous therapy with heparin (bolus of 5,000 U followed by a doseof 800 to 1,200 U/hour) and nitrates. Since 1979, a total of 590 patients (duration of symptoms <6 hours) additionally received thrombolytic therapy. Exclusion criteria for lysis were history of recent trauma, surgery, stroke, known predisposition for bleeding, history of internal (gastrointestinal or genitourinary) bleeding, cancer, hypertension and recent puncture of the subclavian or internal jugular veins. Cardiocompressionregularly was From the Department of Cardiology, Center of Internal Medicine, regarded as exclusion criterion for systemic lysis. During the first years, systemic thrombolytic theraGeorg-August University of Goettingen,Goettingen,Federal Republic of Germany. Manuscript received September 9, 1991;revised manu- py was performed using streptokinase (initially using script receivedand acceptedNovember Z&1991. dosesof 900,000to 3 million U given over 60 minutes’*; Address for reprints: Karl Heinrich Scholz, MD, Department of since 1982,according to the protocol of the Intravenous Cardiology, Center of Internal Medicine, Georg-August University of Streptokinase in Acute Myocardial Infarction study,3 Goettingen,Robert-Koch-Straaae40.3400 Gocttingen,FederalRepub 1.5 million U over 60 minutes). In all patients receiving lit of Germany.

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streptokinase, 1 single dose of aspirin (0.5 to 1.0 g) was administered intravenously. No patient had aspirin medication continued during the first 3 days after lysis. Since 1984, systemic lysis with an increasing frequency was performed with urokinase (bolus of 1.Omillion U, a further 1.Omillion U administered over 60 minutes). In the course of the German Activator Urokinase Study starting in 1985, patients received either recombinant tissue-type plasminogen activator (70 mg over 90 minutes) or a bolus of 1.5 million U of urokinase followed by a further 1.5 million U given over 90 minutes.6 Intracoronary lysis was performed using either strep tokinase (2,000 to 4,000 U/min over 60 to 90 minutes)13or urokinase (250,000 U over 30 minutes). Cardiopulmonary resuscitation: For the present study the records of all patients with thrombolysis were reviewed in detail and all patients were identified who, within a time interval of <24 hours, had been subjected to both cardiocompression and thrombolytic therapy. Patients who had only defibrillation without cardiocompression were not included into the resuscitation group. Data on reasonsfor, as well as time and duration of, resuscitation directly reflect bedside assessmentof the physician who performed resuscitation becausein our hospital important clinical eventsare always immediately documented by the physician in charge. Hemorrhagic compkations: The clinical course of each patient with thrombolysis was analyzed for the following complications occurring within the first 3 days after lysis had begun: decreasein hemoglobin of >2.0 g/dl; any observedorotracheal, gastrointestinal, genitourinary or cerebral bleeding; bleeding at puncture sites of cardiac catheterization; and any bleeding revealedby autopsy studies. During the initial 3 days at least daily controls of hemoglobin were performed in all patients. Statistical analysis: All data were retrospectivelyrecorded and entered into a computerized database.Tests of significance were performed using the chi-square test or Student’s t test, as appropriate.

1

TABLE I Characteristics of 590 Patients with Acute Myocardial Infarction Receiving Thrombolytic Therapy CPR No. of patients Mean age (yr)/range Men Diabetes mellitus Yes No Unknown Hypertension Yes No Unknown Prior myocardial infarction Infarct location Anterior Inferior Undefined Acute invasive interventions Acute angiography Acute angioplasty IABP Hospital death Day 1 Day 2-7 Day >7 Second infarction Hospital stay of survivors (days) *Percentages calculated CPR = cardiopulmonary

No CPR

p Value

43 58.3129-79 33 (77%)

547 58.6127-89 444 (81%)

7 (16%) 25 (58%) 11 (26%)

57 (10%) 429 (78%) 61 (11%)

0.16

129 (24%)

0.64

10 (23%) 21 (49%)

355 (65%) 63 (11%) 84 (15%)

12 (28%) 13 (30%) 22 (51%)

19 (44%) 2 (4.7%) 35 (81%) 33 6 10 20

0.89 0.48

(77%)

271 (49.5%) 274 (50%) 2 (0.5%)

0.62

379 (69%)

0.13

378 (69%)

0.38 0.72

(14%)

95 (17%)

(23%) (46%)

12 (2%) 34 (6%)

13 (65%*) 3 (15%*) 4 (20%*) 3 (7%) 30.4 + 13.3

<0.05


21 (62%*) 13 (38%*) 31 (6%)

0.56

24.8 r 9.4

0.19

from the number of patients who died. resuscitation; IABP = intraaortic ballwn

counterpulsation.

hours. There have been no significant differences between resuscitated and nonresuscitated patients with thrombolysis with regard to age, gender, history of diabetes mellitus, history of hypertension, infarct location and number of patients with invasive interventional procedures(Table I). Intravenous aspirin (0.5 to 1.0 g) was given to 24 patients (56%) with and 309 patients (56%) without resuscitation. The reasonfor resuscitation was ventricular fibrillaRESULTS tionftachycardia in 29, low output in 6, asystole in 6 Thrombolysis and mechanical resuscitation: A total and electromechanical dissociation in 2 patients. The of 43 patients (33 men, 10 women) with acute myocar- average duration of cardiocompressionwas 36 f 32 dial infarction had both thrombolytic therapy and me- minutes (range 4 to 120). Resuscitation initially was chanical resuscitation within a time interval of <24 successfulin 34 patients (79%). In-hospital mortality TABLE II Thrombolysis and Resuscitation in Patients with Myocardial Infarction (n = 43) Start of Lysis Before CPR (5 min-20 hours) (n = 21)

Successful CPR Hospital death Bleeding compllcatlons Mean duration of CPR (min) CPR = cardiopulmonary

I.V.

i.c.

10

10

1

5

-

8 5 3

7 6 2 40.0 (5-90)

1

2 3

-

resuwtatlon;

1.V.lI.C.

1

I.C. = Intracoronary;

After CPR (lo-120 min) (n = 16)

During CPR (n = 6) i.v.

i.c.

i.v./i.c. 1

i.v. 4

I.C.

-

4

10

1

3 2 18.7 (4-30)

1 -

69.2 (40-120)

-

10

i.v./i.c. 2 2 -

1

I.Y. = intravenous.

RESUSCITATION AND THROMBOLYSIS

725

was 46% (20 of 43 patients). Autopsies were performed in 16 of the 20 deceasedpatients. Cause of death was pump failure in 17, arrhythmia in 1, and rupture of the free left ventricular wall in 2 patients. Resuscitation became necessary in 21 patients 5 minutes to 20 hours (5.3 f 5.5 hours) after lysis had begun (Table II). In a further 6 patients, thrombolysis was performed during ongoing cardiocompressionin nearly hopeless clinical situations. Resuscitation was successfulin 2 of these. In both casesangiography revealed a reopened infarct-related coronary vessel. Lysis was initiated in 16 patients after successfulresuscitation; 12 of them receivedintracoronary lysis. In 4 patients, systemic thrombolysis was performed despite preceding resuscitation on the decision of the physician in charge. In thesepatients, mean duration of resuscitation was 8.5 minutes (range 4 to 15) compared with 18.7 minutes for all patients receiving thrombolysis after resuscitation.

ed (x-ray or autopsy) in 17 of the 43 patients. No cerebral hemorrhage was observedin any patient. Complications of thromholysis in resuscitated compared with nonresuscbted patienti There was no sig-

nificant difference in the rate of bleeding complications between43 patients with resuscitation and the 547 patients without mechanical resuscitation (18.6 vs 16.1%; chi-square = 0.34; p = not significant [NS]) (Figure 1). In the group of patients with thrombolysis without resuscitation, major bleeding, defined as a decreasein hemoglobin >5 g/d1 or any intracranial bleeding, occurred in 44 patients (8%). Lethal cerebral bleeding developed in 3 patients. Systemiclysis led to complicationsin 3 of 19 resuscitated (16%) and in 55 of 342 nonresuscitated(16%) patients (chi-square = 0.0, p = NS). For both subgroups, ratios of invasive procedureswere nearly identical (11 of 19 resuscitatedversus 174 of 342 nonresuscitatedpatients). With intracoronary thrombolysis, the rate of bleeding was higher in resuscitated than in nonresusciComp6catktns of thrombotytic therapy in patients with cardiopulmonary resuscitation: Hemorrhagic tated patients (20 vs 15%). This difference, however, complications developedin 8 of the 43 resuscitatedpa- was without statistical significance (chi-square = 0.30). tients with thrombolysis. Five of them had received Similarly, in the few patients receiving combined intrastreptokinaseand 3 urokinase. In 5 patients with bleed- venous and intracoronary lysis, the rate of bleeding ing complications lysis had been performed before re- complications was not significantly different for patients who neededand thosewho did not need (20 vs 25%;chisuscitation becamenecessary. The complications were puncture site bleeding in 3 square = 0.06; p = NS) resuscitation. patients (autopsy/decreasein hemoglobin, 2.9 and 6.7 g/dl), gastrointestinal bleeding in 2 (decreasein hemo- DISCUSSION Cardiopulmonary resuscitationis often regardedas a globin, 2.8 and 4.2 g/dl), mild genitourinary bleeding in 1 patient, and decrease in hemoglobin (2.0 and 6.9 contraindication for thrombolytic therapy because of g/dl) without identification of the site of bleeding in 2 the possiblerisks of fatal hemorrhage.To date, only few casereports exist on thrombolysis in patients with propatients. In no patient was bleeding directly related to cardio- longed resuscitation, and most of them are concerned compression,despite rib fractures that were document- with patients with pulmonary embolism (Table III).

4 2s %

LZ P&with CPR 0 Pk. without CPR

l/4

......... ......... ......... ......... .......... ......... .......... ......... .........

7/ 35 ;{.zz{{<<+ .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... ......... .......... .,............... ... ......... .......... .........

20 -

lS-

lo-

s-

O-

3 119 55’34 .E.‘.‘.‘.’ y::::::: a.*.*.: q:.:.:.. ::::y::: :::::::::: ::::::i:i: :::y.:.: :::::::::: ii::::;:;: .*.a.*.* ::.:.:.:.: ..:.:.:.:. ;;p::: ::&:i. . ::.:.:.:.: ::i:;:i:;: ::...:.:.: ..:::.;.:. ::.:.:.:.: :::::.:.:. ........*. ii ..-.-...-. i.V.

726

i.v.+i.c.

i.c

THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69

MARCH 15, 1992

RGURE 1. Rate of hemorMOhmtidSWRh(Sf@p&d* umns)andwRheut(blanh -w readden (CPR). l%e dlffemocesshewnbetwee!n beulglwpsusingintravenwe (I.V.), f#lhmmq (Le.) md cembined (Lv. + i.e.) ~arewitheutstetistkdsigdicence.

TABLE III Cardiopulmonary myocardial infarction)

Resuscitation and Thrombolysis (pulmonary embolism, Dur. of CPR

Pts., Age Author

& Sex

Diagn.

Renkes ‘7414

F35y

PE

Borst ‘76l5

F35y

PE

Kijstering ‘7716

F 37y

PE

Fliigel ‘78l7 Unseld ‘7818

F35y F49y

Wester ‘8619 Gramann ‘8820 Haugeberg ‘899 Josephs ‘891° Slebenlist ‘90” Horstkotte ‘90**

(min)

LYSIS

Uterine bleeding (4th day after parturition) Hematothorax

PE PE

SK 750,000, +500,000/5 hours SK 1.0 Mio +1.5 Mio/l6 hours SK 750,000 +2.8 Mio/28 hours SK 350,000 SK 750,000

60 15

F27y 10 pts. M 66y M 4Oy 2 pts. 17 pts.

PE ?? AMI AMI PE PE

UK 1.5 MIO SK 1.0 Mio SK 1.5 Mio SK 1.5 Mio rt-PA 100 mg/90 mm. UK (0.5-6.5 Mio)

90 60-100 ? 15 20/30 32-186

Scholz ‘9O23

17 pts.

PE

SK/UK (0.25-6.0

20-160

Jaeger ‘9O24

11 pts.

AMI

SK/UK (1.511.8

Tenaglia ‘912s

22 pts.

AMI

t-PA/UK

Mio) MIO)

Complications

60 8 ?

10x “short” 1x25 110

intraper. bleeding

Decrease In Hb (6 gidl), retroper. bleeding (1st day after hysterectomy) (5 pts died, no autopsy) Hematothorax

2x hematothorax; lx pulmonary bleeding lx sternal hematoma; lx hepatic bleeding -

AMI = acute myocardial Infarction; CPR = cardiopulmonary resuscitation; Diagn. = diagnosis; Dur. = duration; Hb = hemoglobin; mtraper. = intrapentoneal; Mio = million units; PE = pulmonary embolism: retroper. = retropentoneai: rt-PA = recombinant tissue-type plasminogen activator; SK = streptokinase; UK = urokinase; ? = no data reported; ?T = diagnosis unknown (“thorax pain”); - = no bleedingcompllcation.

Substantial bleeding complications occurred in patients with long-term lysis of up to 28 hours,14-16 but appeared to be reduced when high-dose short-term lysis was administered.17-23In our clinic, we observedbleedingsdirectly related to cardiocompressionin only 2 of a total of 17 resuscitated patients with pulmonary embolism who received high dosesof up to 6 million U of streptokinase or urokinase.23However, becauseof considerable differences in both dosageregimens as well as overall duration of resuscitation, theseresults should not simply be applied to patients with acute myocardial infarction. In 1989, Haugeberg et al9 reported on a patient with myocardial infarction who developedintrathoracic hemorrhage after streptokinase lysis following cardiocompression.To our best knowledge, this has been the only report on an apparently lethal outcome of thrombolytic therapy after mechanical resuscitation. In a total of 11 patients with myocardial infarction, Jaegeret a124 observedno complications after short-term lysis following defibrillation or short periods of cardiocompression. Recently, Tenaglia et a125reported no increasedrate of bleeding complications in 22 of 708 patients in the Thrombolysis and Angioplasty in Myocardial Infarction trials who had been resuscitatedand receivedthrombolysis. However, patients with prolonged resuscitation had not been eligible for these trials.25 In contrast, our report includes patients with prolonged resuscitation. We also analyzed the clinical course of patients resuscitatedafter initiation of thrombolytic therapy. In the group of 590 patients with lysis we found no differences in total rates of lysis-related

complications between 43 patients with and 547 patients without resuscitation. In particular, we observed no relevant bleeding directly attributable to cardiocompressiondespite the often prolonged and traumatic resuscitation associatedwith documented rib fractures in one third of the 43 patients. Due to catheter-related bleeding complications,intracoronary lysis in resuscitated patients despite the lower dosage probably brings about no advantageswhen comparedwith systemiclysis (Figure 1). Our study has possiblelimitations. Owing to the retrospective design, some uncertainty exists concerning the severity of bleeding complications. However, routine hemoglobin control measurementsregularly obtained during the first 3 days in each patient prove that no relevant bleeding has been missed. Autopsy studieshave not beenperformed in 4 of our 20 deceasedpatients. Two of these patients died during the first 24 hours. The other 2 died 7 and 20 days after lysis, respectively,without presenting any clinical symptoms of hemorrhage. Finally, there may be withdrawal bias becausepatients with resuscitation are more likely to die, and therefore there might be less opportunity for bleeding problems to manifest in these patients. However, this should be relevant only in patients who died during the period of increasedthrombolytic activity. A total of 13 patients died within the first 24 hours after receiving lysis (Table I). In 9 of these patients, resuscitation had been without primary successand 4 patients died some hours after successfulresuscitation. Although no unre-

RESUSCITATION AND THROMBOLYSIS

727

servedstatementsregarding complications can be given in these patients, there were no clinical or pathologic signs of bleeding in this group. Nevertheless,our study clearly shows that no bleeding complications occurred which were directly related to cardiocompressionin the 30 patients who had had resuscitation and thrombolysis and survived 124 hours. Thus, cardiopulmonary resuscitation, per se, should not be regarded as contraindication for high-dose short-term thrombolytic therapy in patients with myocardial infarction.

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9. HaugebcrgG, Benarjie V, Dickstein K. Fatal intrathoracic haemorrhageafter cardiopulmonaryresuscitationand treatment with streptokinaseand heparin. Br Hearr J 1989;62:157-158. 10. JosephsW, GdenthalHJ, LengaP, WiechmannHW. Erfolgreiche Reanimation durch thrombolytischeTherapie unter maschinellerKardiokompressionbei akutem Verschlussdes linken Hauptstammes.Intenriomed 198926268-271. 11. Scholz KH, Herrmann CH, Tebbc U, Reiss N, Neuhaus KL, Kreuzer H. Decline of in-hospital mortality after acute myocardial infarction during the last ten years: result of acute intervention? Dfsch Med Wochemchr 1988;113: 13051311. 12. Neuhaus KL, Tebbe U, Sauer G, Kreuzer H, Koestering H. High doseof intravenous streptokinasein acute myocardial infarction. Clin Cardiol 1983;6: 426-434. 13. Rentrop KP, Blanke H, Karsch KR, Wiegand V, Koestering H, Oster H,

Leitz K. Acute myocardial infarction: intracoronary application of nitroglycerin and streptokinase.Chin Cardiol 1979;2:354-363. 14. Renkes-HegendoerferU, Herrmann K. Successfultreatment of a case of fulminant massivepulmonary embolismwith streptokinase.Anaesthesist 1974; 23:500-501. 1s. Borst RH, Wolf H. Rapid intravenousinjection of streptokinasein a high initial dose for therapy of a fulminant pulmonary embolism. Anaesthesist 1976;25:398-401. 16. KoesteringH, Moehlenhof 0, FuchsK, Amsel M. ThrombolytischeTherapie bei fulminanter Lungenembolie.Diagn Intenrivtherapie 1977;1:1-5. 17. Flilgel H, Bartels 0, van der Rode J. Behandlungder fulminanten Lungenembolie unter Reanimationsbedingungen.Fortschr Med 1978;96:639-642. 18. UnseldH, Hildebrand MF, HensiusP. Streptokinasebei Lungenemboliemit Herz-Kreislaufstillstand. Awesthesis? 1978;27:333-335. 19. Wester HA, Oregano L, Fenyes-BellmannJ, Huge1E, Kirchhoff PG. Successful treatment of a massivepulmonary embolism after 90-minute external heart massage.Dtsch Med Wochenrchr 1986;111:1151-1154. 20. GramannJ, Lange-BraunP, Hochrein H. Einsatzmdglichkeitender Thrombolyse in der Reanimation. Inrensiumed 1988;25:425-429. 21. SiebenlistD, GattenldhnerW. Kurzzeitlyse mit r&PA bei fulminanter Lungenembolie.Intensiumed 1990;27:302-305. 22. Horstkotte D, Heintzen MP, Strauer BE. Kombinierte mechanischeund thrombolytischeWiedereriiffnung der Lungenstrombahnbei massiverLungenarterienembolie mit kardiogenemSchock. Intensiumed 1990;27:124-132. 23. ScholzKH, Hilmer T, SchusterS, Wojcik J, Kreuzer H, TebbeU. Thrombolysis in resuscitatedpatients with pulmonary embolism.D&h Med Wochenschr 199o;I15930-935. 24. Jaeger A, Macharoui A, Melz F, Scholz-JaegerA, Straub H, Barmeyer J. Systemictibrinolysis after resuscitationor temporary transvenouspacing.Dlsch Med Wochenwhr 1990;115:1009-1013. 25. Tenaglia AN, Califf RM, Candela RJ, KereiakesDJ, Berrios E, Young SY, Stack RS, Top01EJ. Thrombolytic therapy in patientsrequiring cardiopulmonary resuscitation.Am J Cordial 1991;68:1015-1019.

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