What is the approach to tPA (tissue plasminogen activator) administration in a patient with ST-Elevation Myocardial Infarction (STEMI) who goes into cardiac arrest?

From the Guidelines

For a patient with STEMI who goes into cardiac arrest, tPA administration should proceed if the patient achieves return of spontaneous circulation (ROSC) and still meets criteria for thrombolytic therapy, as primary PCI is preferred but may not always be feasible within the recommended time frame 1. The standard tPA regimen for STEMI is a 15mg IV bolus, followed by 0.75mg/kg (maximum 50mg) over 30 minutes, then 0.5mg/kg (maximum 35mg) over the next 60 minutes, for a total dose not exceeding 100mg. Before administering tPA, ensure there are no absolute contraindications such as active internal bleeding, recent stroke, or intracranial pathology. CPR should not be interrupted to administer tPA during active cardiac arrest, as there is no proven benefit and the drug may not circulate effectively without adequate perfusion. Once ROSC is achieved, a rapid reassessment for STEMI criteria and contraindications should be performed. If primary percutaneous coronary intervention (PCI) can be performed within 90-120 minutes of first medical contact, it is preferred over thrombolysis, as outlined in the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation 1. The decision to use tPA should balance the urgency of reperfusion against bleeding risks, which may be heightened after CPR due to chest compressions and potential traumatic injuries. Key considerations include:

• The patient's overall clinical condition and potential for benefit from reperfusion therapy
• The presence of any contraindications to tPA or PCI
• The availability and feasibility of primary PCI within the recommended time frame
• The potential risks and benefits of tPA administration in the context of cardiac arrest and STEMI. According to the 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction, primary PCI is the preferred method of reperfusion when it can be performed in a timely fashion by experienced operators 1. However, the most recent and highest quality study, the 2018 ESC guidelines, emphasizes the importance of considering the individual patient's circumstances and the potential benefits and risks of each treatment approach 1.

From the Research

Approach to tPA Administration in STEMI with Cardiac Arrest

• The administration of tissue plasminogen activator (tPA) in a patient with ST-Elevation Myocardial Infarction (STEMI) who goes into cardiac arrest is a complex issue that requires careful consideration of the patient's overall clinical condition and the potential risks and benefits of tPA therapy 2.
• Current guidelines recommend primary percutaneous coronary intervention (PCI) as the preferred treatment for STEMI, but fibrinolysis with tPA may be considered in certain situations, such as when PCI is not available or is delayed 3, 4.
• In the setting of cardiac arrest, the use of tPA is generally not recommended due to the increased risk of bleeding complications 2.
• However, some studies suggest that tPA may be safe and effective in certain patients with cardiac arrest due to pulmonary embolism, and that the potential benefits of tPA therapy may outweigh the risks in these patients 2.
• The decision to administer tPA in a patient with STEMI and cardiac arrest should be made on a case-by-case basis, taking into account the patient's individual clinical characteristics and the availability of PCI and other treatment options 3, 4, 5, 6.

Considerations for tPA Administration

• The patient's overall clinical condition, including the presence of any contraindications to tPA therapy, such as bleeding disorders or recent surgery 2.
• The availability and timing of PCI, as well as the patient's likelihood of benefiting from PCI 3, 4.
• The potential risks and benefits of tPA therapy, including the risk of bleeding complications and the potential for improved outcomes with timely reperfusion therapy 2, 5, 6.

Alternative Treatment Options

• Primary PCI, which is the preferred treatment for STEMI and may be available in certain situations, even in patients with cardiac arrest 3, 4.
• Mild induced hypothermia, which may be beneficial in comatose survivors of cardiac arrest and may be combined with PCI 5, 6.
• Mechanical cardiopulmonary resuscitation, which may be used to prolong CPR and improve outcomes in patients with cardiac arrest 6.