(951) Evaluation of Alteplase for Pulmonary Embolism in Cardiac Arrest

Introduction: Advanced Cardiovascular Life Support and American Heart Association guidelines suggest thrombolytic therapy for cardiac arrest due to presumed or known pulmonary embolism (PE). The use of fibrin-specific tissue plasminogen activators (tPA) results in rapid thrombolysis and rare but significant risk of bleeding. Conflicting outcomes from available literature show a lack of clear mortality outcomes and dosing strategy, thus leaving such use of thrombolytics controversial. The purpose of this study is to evaluate the safety and efficacy of alteplase use in cardiac arrest for suspected or confirmed PE.

Methods: This multicenter, institutional review board approved, retrospective cohort analysis evaluated patients at least 18 years old who received at least 50 mg alteplase doses in cardiac arrest from 1/1/2018 to 1/1/2023. Exclusion criteria included pregnancy, incarceration, or documented tPA contraindication. Primary outcome included incidence of patients achieving return of spontaneous circulation (ROSC). Secondary outcomes included incidence of survival to hospital discharge, 30-day survival, bleeding events, tPA dosing, cardiopulmonary resuscitation time, time to ROSC, time to tPA administration, heparin drip initiation, intensive care unit length of stay (LOS), and hospital LOS. Descriptive statistics were utilized to characterize baseline demographics and outcome measures.

Results: Nineteen patients (40%) achieved ROSC with three patients surviving to discharge (6%). The most common dosing strategy was 50 mg bolus with two survivors receiving one bolus of 50 mg and one survivor receiving one bolus of 100 mg. The mean time to tPA administration was 24 ± 20 minutes. Bleeding events occurred in five patients (11%) with three patients (6%) having a major bleeding event.

Conclusions: This study shows a high incidence of ROSC but low 30-day survival and survival to discharge despite receiving at least 50 mg of alteplase in the setting of cardiac arrest due to suspected or confirmed PE. Additionally, there is a low incidence of major bleeding events amongst patients who achieved ROSC.