• Indications (Inclusion Criteria - all must be present)
  1. Chest Pain >15 minutes and less than 12 hours
  2. EKG demonstrates STEMI or new LBBB
  • Contraindications
  • Absolute (Exclusion Criteria - all must be absent)
  1. History of prior Intracranial Hemorrhage
  2. Structural CNS Disease
    1. Intracranial neoplasm
    2. AV Malformation
    3. Cerebral Aneurysm
  3. Ischemic Cerebrovascular Accident in last 3 months (but may be indicated if CVA in last 4.5 hours)
  4. Suspected Aortic Dissection (e.g. Systolic Blood Pressure difference between arms >15 mmHg)
  5. Significant Closed Head Injury or facial Trauma in last 3 months
  6. Intracranial or intraspinal surgery in last 2 months
  7. Active bleeding or Bleeding Diathesis (except Menstrual Bleeding)
  8. Severe, Uncontrolled Hypertension, refractory to emergency management
  • Contraindications
  • Relative based on bleeding risk
  1. Chronic, severe and poorly controlled Hypertension
  2. Signficant Hypertension on presentation (SBP >180 mmHg or DBP >110 mmHg)
  3. Major Trauma or surgery (includes Retinal laser surgery) in the last 3 weeks
  4. Internal bleeding (e.g. GI or GU Bleeding) in the last 2-4 weeks
  5. Bleeding or clotting disorder or on blood thinners (e.g. Warfarin and especially with higher INR)
  6. Traumatic or prolonged Cardiopulmonary Resuscitation (CPR) for >10 minutes
  7. Non-compressible vascular puncture
  8. Pregnant female
  9. Active Peptic Ulcer
  10. Dementia
  11. Serious underlying systemic disease
    1. Advanced or terminal cancer
    2. Severe liver disease
    3. Severe Kidney disease
  • Contraindications
  • Relative based on better benefit with PCI (Angioplasty)
  1. Pulmonary Edema
  2. Systolic Blood Pressure <100 mmHg and Heart Rate >100 bpm
  3. Associated shock-related findings (e.g. Cool and clammy skin)
  4. Cardiopulmonary Resuscitation was needed
  1. Tenecteplase (TNK-tPA)
    1. Single weight-based dose, with high fibrin Specificity and 85% patency rate at 90 minutes
  2. Reteplase (rPA)
    1. Two 10 unit doses at 30 minute intervals with moderate fibrin Specificity, and 84% patency rate at 90 min
  3. Alteplase (tPA) - typical standard agent used in U.S. as of 2017
    1. Bolus and infusion over 90 minutes with moderate fibrin Specificity, and 73 to 84% patency rate at 90 min
  4. Streptokinase
    1. Older agent, replaced by Fibrin specific agents
    2. Highly Antigenic and Streptokinase cannot be repeated within 6 months of prior dose
    3. Not available in U.S., but still used in some parts of world, with patency rates 60 to 68% at 90 min
  1. Weight 67 kg or less
    1. Bolus: 15 mg IV
    2. Next: 0.75 mg/kg (max 50 mg) IV over 30 minutes
    3. Next: 0.5 mg/kg (max 35 mg) IV over 60 minutes
  2. Weight more than 67 kg
    1. Bolus: 15 mg IV
    2. Next: 50 mg IV over 30 minutes
    3. Next: 35 mg IV over 60 minutes
  1. Goal: Thrombolytics in Acute MI within 30 min
  2. Mortality related to delay in Thrombolytic use
    1. Meta-analysis: 50,246 patients in 22 trials 1983-1993
      1. Thrombolytic delayed 0-1 hours: 65/1000 lives saved
      2. Thrombolytic delayed 1-2 hours: 37/1000 lives saved
      3. Thrombolytic delayed 2-3 hours: 26/1000 lives saved
      4. Thrombolytic delayed 3-6 hours: 29/1000 lives saved
    2. Reference
      1. Boersma (1996) Lancet 348:771-5 [PubMed]