2025 Southeastern Residency Conference

Title: Evaluating the Safety and Efficacy of Thombolytics in the Setting of Cardiac Arrest
Authors: Elliott Wilch and Derrick Clay


Background: Cardiac arrest refers to circulatory collapse that results in cessation of cardiac function that is either restored by resuscitative efforts or results in cardiac death. Each year there are over 350,000 out of hospital cardiac arrests, which is associated with poor outcomes with only 10.6% of patients surviving to hospital discharge. Cardiac arrest is typically managed with standard resuscitative modalities such as advanced cardiac life support (ACLS). Thrombolytic agents, such as tenecteplase and alteplase can be used in conjunction with ACLS to help restore circulation by initiating fibrinolysis in cardiac arrest due to pulmonary embolism or coronary thrombosis. Data surrounding the use of thrombolytic agents in the setting of cardiac arrest is lacking. Studies have found varying results surrounding outcomes such as survival to hospital discharge and return of spontaneous circulation. Regardless of the lack of definitive data surrounding thrombolytics in cardiac arrest, both the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and the European Resuscitation Council Guidelines for Cardiac Arrest in Special Circumstances recommend their use in this setting. The following study will be conducted to assess the safety and efficacy of thrombolytic agents in the setting of undifferentiated, out of hospital cardiac arrest.  


Methods: This is a single-center, retrospective cohort study assessing the safety and efficacy of thrombolytics in the setting of cardiac arrest. Patients 18 years or older with the primary diagnosis of cardiac arrest who received an IV thrombolytic agent were included in the study. Patients were excluded if they were pregnant or incarcerated. The group of patients who received a thrombolytic agent during cardiac arrest was then. compared to a historical control group of similar demographics. The primary outcome was return of spontaneous circulation. Secondary outcomes included survival to hospital admission, survival at 24-hours, survival to hospital discharge, and neurologically intact survival defined as a Modified Rankin score of less than or equal to two. Safety outcomes included major and minor bleeding complications. 


Results: Among the 144 patients initially reviewed, thirty-two patients did not meet the inclusion criteria for various reasons. Of the 112 patients included in the study, forty-three were assigned to the thrombolytic group and sixty-nine to the no thrombolytic group. The primary outcome, ROSC, for the intervention group versus control group was 32.6% and 53.6% respectively (P=0.029). The results for the thrombolytic group versus no thrombolytic group for secondary outcomes of survival to hospital admission (16.3% vs 31.9%, p=0.067), survival at 24-hours (11.6% vs 15.9%, p=0.526), survival to hospital discharge (4.7% vs 2.9%, p=0.637) and neurologically intact survival (4.7% vs 2.9%, p=0.637) were also calculated.


Conclusion: When examining the use of thrombolytics in the setting of cardiac arrest, the primary outcome was achieved at a higher rate in the group who did not receive a thrombolytic agent. It is important to note that this trial was underpowered due to limited patient enrollment, primarily attributable to the lack of thrombolytic usage during cardiac arrest. While this trial may not have shown a benefit of thrombolytics in the primary and secondary outcomes, the American Heart association and European resuscitation council guidelines for cardiac arrest recommend early administration of thrombolytics as opposed to late. In this study, the average time from presentation to thrombolytic administration was 17.4 minutes indicating that thrombolytics were potentially used as a last line effort in the setting of cardiac arrest, leading to the outcomes seen in this study.

ewilch@srhs.com