pharmacological management of cardiac arrest after st

Pharmacological management

of cardiac arrest

after ST-elevation myocardial infarction

Uwe Zeymer,

Klinikum Ludwigshafen, Med. Klinik B

ESC Congress Munich 27 August 2012

Disclosures

Speakers honoraria and member of

advisory boards from:

Astra Zeneca, Boehringer Ingelheim,

Bayer Healtcare, Daiichi Sankyo, Eli Lilly,

Medicines Company, MSD, Novartis,

Sanofi

Background

The prognosis of patients with STEMI admitted to hospitals has substantially improved over the years

However high risk subgroups of patients with STEMI remain:

- patients with the need for CPR

- patients with cardiogenic shock

Koeth, Zeymer, Am J Cardiol 2012

Patients with confirmed STEMI and prehospital

CPR Results of the PREMIR-Registry

Initial heart rhythm and

mortality after CPR for STEMI


Patients with confirmed STEMI and prehospital

CPR – Results of the PREMIR-Registry

190 patients with STEMI and pre-hospital resuscitation

107 patients received

pre-hospital thrombolysis

101 patients survived pre-hospital phase

52 (51.5 %) patients received early PCI

Hospital mortality was 26.9 % (14/52)

49 (48.5 %) patients received

no additional reperfusion therapy


6 (5.6 %) patients died before hospital admission

83 patients received no pre-hospital thrombolysis

79 patients survived pre-hospital phase

54 (68.4 %) patients received primary PCI


15 (19.0 %) patients received no reperfusion therapy

Hospital mortality was 66.7% (10/15)

10 (12.6 %) patients received hospital thrombolysis

Hospital mortality was 30 % (3/10)

4 (4.8 %) patients died before hospital admission


Problems to identify

patients with STEMI in the group of

patients with CPR

Symptoms ? (Chest pain)

History ? (Known CAD, risk factors)

ECG

Cardiac markers

So the diagnosis of a large proportion of

patients in the RCTs remains uncertain

Therapeutic options after

CPR for STEMI

Antiarrhytmic therapy

Catecholamines

Antithrombotic therapy

Reperfusion therapy

Hypothermia

Antiarrhythmic therapy

Lidocaine had been the standard of care

for a long time

Prophylactic lidocaine has been shown to

worsen prognosis in STEMI

Amiadoran more effective than lidocaine in

suppressing ventricular arrhythmias

Pat. with refractory VF (at least 3 shocks)

n = 504

Hospital 34 % - p = 0.03 - 44 %

admission (n = 88) (n = 108)

Hospital 13,2 % - n.s. - 13,4 %

discharge (n = 34) (n = 33)

„Hypotension“ 48 % - p = 0.04 - 59 %

„Bradykardia“ 25 % - p = 0.004 - 41 %

Kudenchuk et al, NEJM 1999

Placebo

n = 258

Amiodaron 300 mg

n = 246

ARREST – Study Rate of patients with STEMI unknown

ALIVE – Study

Pat. with refractory VF

n = 347

5 mg/kg Amiodaron max. 600 mg

n = 179

1,5 mg/kg Lidocain

n = 165

Hospital 22,7 p < 0.005 11 %

admission n = 41 n = 18

Dorian et al, NEJM 2002

Rate of patients with STEMI not reported

Antiarrhythmic therapy

in CPR for STEMI

Amiodarone 300 mg/kg bolus in patients

with VF/VT not responding to defibrillation

Lidocaine not an option

Catecholamines

Epinephrine is standard of care for

patients with cardiac arrest and

recommended in the guidelines

Most patients with CPR need a

vasopressor to achieve sufficient cerebral

and coronary perfusion

Recently the value of epinephrine has

been questioned

Vasopressin versus

epinephrine in CPR

Wenzel et al; NEJM 2004: 350: 105-113

Epinephrine in out of

hospital cardiac arrest

Hagihara et al, JAMA 2012; 307: 1161-68


No trials in patients with STEMI and CPR

But beneficial in patients with STEMI

Therefore recommendet after CPR for

STEMI


Aspirin 500 mg intravenously

GP IIb/IIIa inhibitors in case of intended

primary PCI

Enoxparin 0.5 mg/kg or unfractionated

heparin 70-100 IU /kg bolus

In-hospital events in patients

with cardiogenic shock

Results of the ALKK-PCI registry

36,4

0,4 0,22,4

45,6

0,2 0,2 1,9

0

10

20

30

40

50

Death NF Re-MI NF stroke Bleeding

GP IIb/IIIa (n=889) No GP IIb/IIIa (n=538)

Upfront abciximab before PCI for

cardiogenic shock

Prague-7 study (n=80)

Tousek et al, Acute Cardiac Care 2011

100 % abciximab (group A) versus 35 % Abciximab (group B)

Events day 30 (%)

Fibrinolysis

STEMI is caused in over 90% by a

thrombotic occlusion

Fibrinolysis is able to recanalize the infarct

related artery in about two thirds of the

patients

Therefore fibrinolysis might be an option

after CPR for suspected STEMI

Smaller non-randomized trials suggested

a benefit

The TROICA-trial

Patients with cardiac arrest of presumed

cardiac origin

Start of basic or advanced life support

within 10 minutes after collapse

Direct inclusion in case of asystole or

PEA, in cases of VF or VT 3 ineffective

attempts of defibrillation

Randomization to tenecteplase or placebo

Primary endpoint: 30-day survival

Böttiger et al, NEJM 2008; 359: 2651-60

Baseline characteristics


Results

54,6 55

33,3

17,5 17

55 53,5

30,6

15,1 14,7

0

10

20

30

40

50

60

ROSC Hospitaladmission

24-hr hospitaldischarge

30 days

Placebo Tenecteplase


Fibrinolysis

Should not be used in cases with asystole

or PEA

Might be an option in patients with CPR for

VF and documented STEMI

Should not be a stand-alone therapy but

followed by coronary angiography and PCI

Summary

The prognosis of patients with STEMI and

cardiac arrest remains poor

For early stabilization amiodaron and

epinephrine helpful, but unclear effect on

in-hospital survival

Early reperfusion therapy with PCI

improves outcome

Fibrinolysis might be helpful in selected

patients

pharmacological management of cardiac arrest after st

Documents