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MI Thrombolysis

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MI Thrombolysis, Fibrinolysis for ST Elevation MI, Myocardial Infarction Thrombolysis, Thrombolysis in STEMI, Thrombolysis in ST Elevation Myocardial Infarction, MI Fibrinolytic Checklist, Acute Coronary Syndrome Thrombolytic Contraindications, Thrombolysis of Coronary Artery by Intravenous Infusion

  • See Also
  1. Thrombolytic
  2. Thrombolysis in Massive Pulmonary Embolism
  3. Thrombolysis in Cerebrovascular Accident
  4. t-PA (Alteplase)
  5. ST Elevation MI (STEMI)
  • 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
  • Protocol
  1. See High Risk Acute Coronary Syndrome Management (STEMI)
  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]
  • References
  1. O'Gara (2013) Circulation 127(4):e362-425 +PMID:23247304 [PubMed]
  2. O'Conner (2010) Circulation 122(18 Suppl 3):S787-817 +PMID:20956226 [PubMed]