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.