Cardiac Thrombolysis for Occlusive MI/STEMI

Related Subjects: |Atherosclerosis |Ischaemic heart disease |Assessing Chest Pain |ACS: general |ACS: STEMI |Cardiac Thrombolysis |Stroke Thrombolysis |Alteplase |Tenecteplase |Streptokinase |Reteplase |ACS: Right Ventricular STEMI

Thombolysis has been the cornerstone of treatment for patients having ST segment elevation myocardial infarctions (STEMI) by improving outcomes and preserving left ventricular function but has largely been replaced by Primary PCI. Door-to-needle time should be <30 min

Usual Criteria (take advice if unsure)

• STEMI AND symptoms onset <12 h prior may consider up to 24 h after sx onset if persistent sx, ongoing STE, rising troponin, haemodynamic instability, & pPCI unavailable
• 1mm of ST segment elevation from the J point in at least 2 contiguous limb leads (I, II,III, AVF and AVL)
• 2mm of ST segment elevation from the J point in at least 2 contiguous chest leads (any two of V1 to V6)
• New onset LBBB

Absolute Contraindications

• Possibility of a dissecting aortic aneurysm. Get a CTA if unsure
• Ischaemic stroke within 3 months (except if acute and within 4.5 hours of symptom onset when it is a treatment
• Intracranial neoplasm or arterio-venous malformation
• Active bleeding which cannot be controlled
• Active bleeding diathesis
• Recent GI haemorrhage or symptoms suggesting active peptic ulcer
• Uncontrolled hypertension (systolic>180mmHg or diastolic >100mmHg),
• Significant closed-head trauma or facial trauma within 3 months.
• Bleeding tendency
• Recent surgery especially intracranial or intraspinal surgery
• Recent trauma with risk of haemorrhage
• Cancer with risk of bleeding
• Intracranial haemorrhage at any time

Relative Contraindications (take senior advice)

• BP > 180/110 mmHg (Consider IV labetalol)
• Severe chronic hypertension at risk of ICH
• Trauma < 2 weeks
• Recent GI or another bleeding especially if uncontrolled
• Rigorous CPR > 10 minutes
• Active peptic ulceration
• Warfarin therapy - check INR
• Recent DOAC or high dose LMWH
• Active menstruation, pregnancy
• Cancer with or without metastases
• Haemorrhagic or diabetic retinopathy
• Abdominal aortic/thoracic aneurysm
• Invasive or surgical procedure < 3 weeks

Side effects

• Bleeding
• Anaphylaxis
• Angioneurotic oedema

Management

• Tenecteplase
• Streptokinase
• Reteplase

Life threatening Bleeding due to Thrombolysis

• IV fluids and packed cells as needed
• Begin with 10 units of cryoprecipitate and obtain fibrinogen levels.
• If the fibrinogen level is <1 g/L, administer a second 10 U of cryoprecipitate.
• If bleeding continues despite a fibrinogen >1 g/L, or if the fibrinogen level is <1 g/L after 20 U of cryoprecipitate, administer 2 U of FFP.
• If hemorrhage continues, administer platelets or antifibrinolytic agents such as aminocaproic acid or tranexamic acid