Makindo Medical Notes

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

💡 Note: Thrombolysis has been a cornerstone of STEMI management, improving survival and LV function. ⚠️ It is now largely replaced by Primary PCI where available. ⏱️ Target door-to-needle time <30 min.

📋 Usual Criteria for Thrombolysis (seek advice if unsure)

• STEMI with symptom onset <12 h (consider up to 24 h if ongoing pain/instability).
• Persistent chest pain + ongoing ST elevation / rising troponin / haemodynamic instability.
• Primary PCI unavailable within recommended timeframe.
• ECG criteria:
  • ≥1 mm ST elevation in ≥2 contiguous limb leads (I, II, III, aVF, aVL).
  • ≥2 mm ST elevation in ≥2 contiguous chest leads (V1–V6).
  • New-onset LBBB with ischaemic symptoms.

⛔ Absolute Contraindications

• Suspected/confirmed aortic dissection.
• Ischaemic stroke <3 months (unless acute ischaemic stroke <4.5 h being treated with thrombolysis).
• History of intracranial haemorrhage, AVM, or intracranial neoplasm.
• Active internal bleeding / known bleeding diathesis.
• Recent GI bleed, peptic ulcer, or major trauma/surgery (esp. intracranial/spinal).
• Severe uncontrolled hypertension (SBP >180 mmHg or DBP >100 mmHg).
• Recent significant head/facial trauma (<3 months).
• Cancer with very high bleeding risk.

⚠️ Relative Contraindications (seek senior advice)

• Severe chronic hypertension (>180/110 mmHg) → may lower BP first (e.g. IV labetalol).
• Recent trauma (<2 weeks) or major surgery (<3 weeks).
• Prolonged CPR >10 min (risk of trauma-related bleeding).
• Active peptic ulcer, recent GI bleeding.
• Pregnancy, active menstruation.
• Current anticoagulation (warfarin → check INR; DOACs/LMWH → high risk).
• Diabetic or haemorrhagic retinopathy.
• Known abdominal/thoracic aortic aneurysm.

⚠️ Side Effects

• 🩸 Bleeding – most common and serious (GI, intracranial).
• 🤧 Anaphylaxis – rare, esp. with streptokinase.
• 😮‍💨 Angioedema – more likely in patients on ACE inhibitors.

🩺 Management of Life-Threatening Bleeding

• Resuscitate: IV fluids, packed red cells as required.
• Give 10 units cryoprecipitate → check fibrinogen.
• If fibrinogen <1 g/L → repeat 10 units cryoprecipitate.
• If bleeding persists and fibrinogen ≥1 g/L, or refractory low fibrinogen → give 2 units FFP.
• Consider platelets, tranexamic acid, or aminocaproic acid if bleeding ongoing.

💊 Thrombolytic Agents

• Tenecteplase – single bolus, weight-adjusted.
• Streptokinase – older agent, antigenic, allergic reactions possible.
• Reteplase – given as 2 IV boluses, easier administration.