27 January 2026: Articles 
Thrombolytic Therapy After Return of Spontaneous Circulation in Patients With STEMI From Medically Underdeveloped Areas: A Case Series
Management of emergency care
Jiacheng Lai ABCE 1,2, Chongjian Huang
AB 2,3, Lei Wang B 4, Renli Cheng B 3, Qingtong Wang FG 5, Yongsheng Han AFG 2,6*
DOI: 10.12659/AJCR.949976
Am J Case Rep 2026; 27:e949976
Abstract
BACKGROUND: Although current guidelines classify prolonged cardiopulmonary resuscitation (CPR) as a relative contraindication to thrombolytic therapy, this treatment may serve as a viable reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI) who achieve return of spontaneous circulation (ROSC) when primary percutaneous coronary intervention (PCI) cannot be performed in a timely manner or is unavailable. This case series evaluated the safety and efficacy of thrombolytic therapy after ROSC in 12 patients with STEMI.
CASE REPORT: Twelve patients with STEMI (9 men and 3 women; mean age, 64.33 years) who had just returned to continuous spontaneous circulation via CPR received thrombolytic therapy at 3 hospitals (Hospital I, 1 patient; Hospital II, 9 patients; Hospital III, 2 patients) between April 2007 and February 2021. Electrocardiography showed anterior wall elevation in 66.7% and inferior wall elevation in 33.3% of patients; the ischemic site was independent of CPR duration (P=0.890). CPR duration was associated with a higher incidence of rib fractures (P=0.02) but not bleeding complications (P=0.160). Binary logistic regression analysis showed no correlation between CPR duration and grade of bleeding complications (odds ratio=1). Of the 8 long-term survivors, 1 had mild neurological sequelae.
CONCLUSIONS: Our findings support the safety and feasibility of post-ROSC thrombolysis as a therapeutic option for patients with STEMI after comprehensive clinical evaluation, particularly in resource-limited settings where primary PCI is unavailable. This approach achieves restoration of coronary perfusion and has a potential neuroprotective effect in survivors of cardiac arrest.
Keywords: Brain Injuries, Myocardial Infarction, Thrombolytic Therapy
Introduction
Cardiac arrest (CA) remains a leading cause of mortality, responsible for approximately half of all cardiovascular disease–related deaths. Most sudden cardiac arrests result from lethal arrhythmias, primarily triggered by acute myocardial infarction, particularly ST-segment elevation myocardial infarction (STEMI) [1]. Although cardiopulmonary resuscitation (CPR) is the initial intervention for patients with STEMI after cardiac arrest, early reperfusion therapy is critical to improve long-term survival. Reperfusion strategies include thrombolytic therapy, primary percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Current guidelines recommend primary PCI as the preferred reperfusion strategy for patients with STEMI, ideally within 120 min of hospital admission [2,3]. However, in medically underdeveloped regions, timely primary PCI is often unavailable, making thrombolytic therapy a viable alternative.
Recent studies have increasingly demonstrated the efficacy of thrombolytic therapy in STEMI management [3–6]. Additionally, PCI after thrombolysis has been proposed for patients unable to undergo immediate primary PCI [4,5]. There is evidence that administering thrombolytic therapy within 6 h of symptom onset can prevent 30 early deaths per 1000 treated patients; treatment benefits are strongly time dependent [2]. Although prolonged CPR is considered a relative contraindication to thrombolysis [2], this approach may constitute a feasible reperfusion option for patients with STEMI who achieve return of spontaneous circulation (ROSC) when primary PCI is delayed or inaccessible.
This case series investigated the safety and efficacy of thrombolytic therapy after ROSC in 12 patients from medically underdeveloped areas who had electrocardiographic manifestations of STEMI.
Case Reports
POPULATION:
From April 2007 to February 2021, we identified 19 patients with STEMI who achieved ROSC and were candidates for thrombolytic therapy. Of these, 12 patients (Hospital I: n=1; Hospital II: n=9; Hospital III: n=2) received thrombolysis and were included in this case series. The remaining 7 patients were excluded because family members declined thrombolytic treatment. The primary endpoint was patient follow-up at 1 year after ROSC, and the secondary endpoint was all-cause mortality.
INCLUSION CRITERIA:
Patients were included in this case series if they met the diagnostic criteria for STEMI, if the onset of cardiac arrest occurred within 120 min of successful CPR, if no absolute contraindication to thrombolytic therapy was present, if primary PCI was unavailable, and if signed informed consent for thrombolytic therapy was provided [2].
THROMBOLYTIC THERAPY PROTOCOLS:
Thrombolytic therapy consisted of urokinase or prourokinase. Urokinase (1.5 million units) was dissolved in 100 mL of saline and infused intravenously over 30 min. Recombinant human prourokinase (rhPro-UK; 20 mg) was dissolved in 10 mL of saline and injected over 3 min; this was followed by dissolution of 30 mg of rhPro-UK in 90 mL of saline and infusion over 30 min.
EVALUATION CRITERIA:
Thrombolytic therapy success criteria consisted of [2]: ST-segment resolution greater than 50% at 60 to 90 min, typical reperfusion arrhythmia, and disappearance of chest pain.
The Bleeding Academic Research Consortium (BARC) definition for bleeding [7] was used to assess bleeding (computed tomography examination completed 24 h after thrombolytic therapy):
Cerebral Performance Category (CPC) scores [8] were implemented as follows:
Time management process of acute myocardial infarction:
STATISTICAL ANALYSIS:
Data are presented as mean and standard deviation or median for numerical variables. Unpaired 2-tailed t-tests were performed to compare means. Binary logistic regression was used to analyze the relationship between grade of bleeding and CPR duration. Analyses were conducted using SPSS 26.0 software.
PATIENT CHARACTERISTICS:
In total, 12 patients were included (in-hospital cardiac arrest [IHCA], n=6; out-of-hospital cardiac arrest [OHCA], n=6). All patients initially presented with chest pain and chest tightness. The mean age was 64.33 years, and 75% were men. The mean age of non-survivors was 71.75 years, higher than the 62.15 years observed in survivors (P<0.05). Five patients had a history of cardiovascular disease (coronary heart disease or cerebral infarction). ECG findings showed anterior wall involvement in 16.7%, extensive anterior wall involvement in 50%, and inferior wall involvement in 33.3%; the ischemic site was independent of CPR duration (P>0.05) (Figure 2). Comparison of IHCA and OHCA groups revealed no statistically significant differences in baseline characteristics (P>0.05). Among 5 patients who were taking long-term oral aspirin, 4 had hypertension and 1 had diabetes.
PATIENTS’ SEQUELAE AND OUTCOMES:
All 12 patients received dual antiplatelet therapy, 8 of whom received aspirin with clopidogrel; the remainder received aspirin with ticagrelor. Thrombolytic therapy, administered using urokinase (n=3) or rhPro-UK (n=9), was successful in 11 cases. Among these patients, 6 had no bleeding, 1 had BARC type 1 bleeding, 2 had BARC type 2 bleeding, and 1 had BARC type 5 bleeding. Rib fractures occurred in 7 patients (IHCA, n=3; OHCA, n=4); this occurrence was associated with CPR duration (P=0.02) but not with bleeding complications (P=0.160) (Figures 3, 4). Binary logistic regression analysis indicated no correlation between CPR duration and the grade of bleeding complications (odds ratio=1.00; 95% confidence interval, 0.05–20.83; P>0.05). Six patients underwent delayed PCI. Three patients died in-hospital (all in the OHCA group); survival outcome was not significantly associated with CPR duration (P=0.423) (Figure 5). Treatment outcomes did not significantly differ between IHCA and OHCA groups (Table 1). Only 1 of the 8 long-term survivors had mild neurological sequelae (Table 2).
Although thrombolytic therapy was successful in patient 3, defined by ST-segment resolution greater than 50% at 60 min, gastrointestinal bleeding occurred, and hemoglobin dropped from 116 g/L to 50 g/L. Red blood cells (2800 mL) were transfused, but the patient failed to improve. No intracranial hemorrhage was detected via computed tomography during hospitalization. Brain function recovery was poor (CPC=4), and the patient died after further rescue attempts.
Patient 7 achieved ROSC 10 min after the first CPR, but subsequent thrombolytic therapy was unsuccessful, and another cardiac arrest occurred. ROSC was not achieved again.
In patient 8, thrombolytic therapy after ROSC was successful, and no cerebral hemorrhage occurred. However, the patient remained in a deep coma (CPC=4) and died after 10 days.
Patient 2 was successfully discharged after thrombolytic therapy but experienced sudden cardiac death 6 months later. This fatal event may have been related to the inability to perform the indicated delayed PCI.
Discussion
LIMITATIONS:
The main limitation of this case series is the small sample size, which reflects the number of patients with STEMI who received thrombolysis after ROSC. This limitation arose because intravenous thrombolysis is unlikely to be considered when timely primary PCI is available.
Conclusions
This case series provides clinical evidence supporting the safety and feasibility of post-ROSC thrombolysis as a therapeutic option for patients with STEMI after comprehensive clinical evaluation, particularly in resource-limited settings where primary PCI is unavailable. Our results demonstrate that this approach achieves dual therapeutic benefits: restoration of coronary perfusion and a potential neuroprotective effect in survivors of cardiac arrest.
Figures
Figure 1. Time management process of acute myocardial infarction. STEMI – ST-segment elevation myocardial infarction. 
Figure 2. Relationship between electrocardiography site and CPR duration. CPR – cardiopulmonary resuscitation. 
Figure 3. Relationship between rib fractures and duration of CPR. CPR – cardiopulmonary resuscitation. 
Figure 4. Relationship between rib fractures and BARC type. BARC – Bleeding Academic Research Consortium. 
Figure 5. Relationship between survival outcome and duration of CPR. CPR – cardiopulmonary resuscitation. 
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Figures
Figure 1. Time management process of acute myocardial infarction. STEMI – ST-segment elevation myocardial infarction.Figure 2. Relationship between electrocardiography site and CPR duration. CPR – cardiopulmonary resuscitation.Figure 3. Relationship between rib fractures and duration of CPR. CPR – cardiopulmonary resuscitation.Figure 4. Relationship between rib fractures and BARC type. BARC – Bleeding Academic Research Consortium.Figure 5. Relationship between survival outcome and duration of CPR. CPR – cardiopulmonary resuscitation. In Press
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