From the Guidelines
To treat asystole, immediate cardiopulmonary resuscitation (CPR) with high-quality chest compressions and administration of epinephrine 1 mg intravenously or intraosseously every 3-5 minutes is essential. Begin with chest compressions at a rate of 100-120 compressions per minute, allowing for complete chest recoil between compressions. Establish an airway and provide ventilation with a bag-mask device. While doing this, identify and treat any reversible causes such as hypoxia, hypovolemia, hypothermia, acidosis, or drug overdose. Asystole represents the absence of any electrical activity in the heart, resulting in no cardiac output. Unlike ventricular fibrillation, asystole does not respond to defibrillation, which is why CPR and epinephrine are the mainstays of treatment. The goal of epinephrine is to increase coronary perfusion pressure and stimulate cardiac activity, as supported by the study on vasopressors for cardiac arrest 1. Unfortunately, asystole generally carries a poor prognosis, and after 20-30 minutes of unsuccessful resuscitation efforts with no return of spontaneous circulation, termination of resuscitation may be considered.
Some key points to consider in the treatment of asystole include:
- The use of vasopressors, such as epinephrine, to improve outcomes 1
- The importance of identifying and treating reversible causes of asystole
- The need for high-quality CPR with proper chest compression technique
- The potential use of other medications, such as antiarrhythmic drugs or buffering agents, although the evidence for these is less clear 1
- The consideration of termination of resuscitation efforts after a prolonged period of unsuccessful resuscitation.
It is also important to note that the treatment of asystole should be guided by the most recent and highest quality evidence, and that the use of any medication or intervention should be carefully considered in the context of the individual patient's situation. In this case, the study on vasopressors for cardiac arrest 1 provides the most relevant and up-to-date guidance on the treatment of asystole.
From the Research
Treatment of Systole
To treat a systole, the following steps can be taken:
- Determination of volume status and appropriate diuretic administration is important in heart failure management 2
- Inhibition of the renin-angiotensin-aldosterone and sympathetic nervous systems improves survival and decreases hospitalizations in patients with systolic or reduced ejection fraction HF (HFrEF) 2
- Beta blockers and aldosterone antagonists improve ejection fraction 2
- Treat hypertension with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers 3
- Treat myocardial ischemia with nitrates and β-blockers 3
- Treat volume overload and HF with diuretics 3
- Treat HF with ACE inhibitors and β-blockers 3
- Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in chronic symptomatic HF and abnormal LV ejection fraction 3
Medications
The following medications can be used to treat systole:
- Diuretics to relieve symptoms 2, 3, 4
- β-blockers as foundational therapy 2, 3, 4
- Angiotensin receptor-neprilysin inhibitor, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker as foundational therapy 4
- Mineralocorticoid receptor antagonist in patients with persistent symptoms 4
- Ivabradine and hydralazine/isosorbide dinitrate in certain patients with HFrEF 4
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors to reduce cardiovascular and all-cause mortality 4
- Vericiguat, a soluble guanylate cyclase stimulator, to reduce heart failure hospitalization in high-risk patients with HFrEF 4
Device Therapies
Device therapies may be beneficial in specific subpopulations, such as:
- Cardiac resynchronization therapy in patients with interventricular dyssynchrony 4
- Transcatheter mitral valve repair in patients with severe secondary mitral regurgitation 4
- Implantable cardiac defibrillators in patients with more severe left ventricular dysfunction particularly of ischemic etiology 4