Fibrinolysis:
- In the absence of contraindications, should be given to STEMI patients with symptoms <12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact (class I recommendation)
- Up to 12-24 hours of symptoms with STEMI when PCI unavailable (class IIa recommendation)
When to choose thrombolytics?
- Non-PCI capable hospital and the total time it would take to transfer to a PCI-capable hospital and first medical contact–device time is > 120 min away
- Ideally administered within the first 30 minutes of presentation
Thrombolytic agents:
- tPA: 15 mg IV over 1-2 min, followed by 50 mg IV over 30 min, followed by 35 mg IV over 60 min (total 100 mg over 1.5 hours)
- TNKase: 30-50 mg IV over 5 sec (dosing is weight based)
- rPA: 10 Units x 2 given 30 min apart
Absolute contraindications:
- Any prior intracranial hemorrhage
- Ischemic stroke within 3 months (except acute ischemic stroke within 4.5 hrs)
- Known structural cerebral vascular lesion (e.g. AVM) or intracranial neoplasm (primary or metastatic)
- Active bleeding or bleeding diatheses (excluding menses)
- Intracranial or intraspinal surgery within 2 months
- For streptokinase, prior treatment within the previous 6 months
- Significant closed-head or facial trauma within 3 months
- Suspected aortic dissection
- Severe uncontrolled hypertension unresponsive to emergency therapy
Adjunctive Therapies to thrombolytics:
- Aspirin: 162 to 325 mg loading dose
- Clopidogrel: 300 mg for ≤75 years old; 75 mg for >75 years old
- Unfractionated heparin bolus or enoxaparin or fondaparinux
Final points:
- Transfer! Regardless of hemodynamics or reperfusion success, it is reasonable to still get patients to a PCI-capable center.
- Angiography recommended within the first 24 hours but AVOIDED for the first 2-3 hours after fibrinolytic therapy.
