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
Thrombolysis has been a cornerstone of treatment for patients with ST-segment elevation myocardial infarctions (STEMI), improving outcomes and preserving left ventricular function. However, it has largely been replaced by Primary PCI in many settings. The door-to-needle time for thrombolysis should be <30 minutes.
Usual Criteria for Thrombolysis (seek advice if unsure)
- STEMI with symptom onset <12 hours prior (may consider up to 24 hours in some cases).
- STEMI with persistent symptoms.
- STEMI with ongoing ST elevation, rising troponin levels, or haemodynamic instability.
- Primary PCI is unavailable.
- ≥ 1 mm of ST elevation in at least 2 contiguous limb leads (I, II, III, AVF, AVL).
- ≥ 2 mm of ST elevation in at least 2 contiguous chest leads (V1-V6).
- New onset left bundle branch block (LBBB).
Absolute Contraindications
- Suspected or confirmed dissecting aortic aneurysm (consider CTA if unsure).
- Ischaemic stroke within the last 3 months (seek advice if acute stroke is suspected).
- Known intracranial neoplasm or arteriovenous malformation.
- Active, uncontrollable bleeding.
- Known bleeding diathesis.
- Recent gastrointestinal haemorrhage or active peptic ulcer disease.
- Uncontrolled hypertension (systolic BP >180 mmHg or diastolic BP >100 mmHg).
- Significant closed-head or facial trauma within the past 3 months.
- History of intracranial haemorrhage.
- Recent intracranial or intraspinal surgery.
- Recent trauma with high risk of haemorrhage.
- Cancer with a high risk of bleeding.
Relative Contraindications (seek senior advice)
- Severe chronic hypertension (BP >180/110 mmHg) – consider IV labetalol.
- History of haemorrhagic stroke or intracerebral haemorrhage (ICH).
- Trauma within the past 2 weeks.
- Recent gastrointestinal bleeding or uncontrolled bleeding.
- Prolonged CPR (>10 minutes).
- Active peptic ulcer disease.
- Patients on warfarin – check INR.
- Recent use of direct oral anticoagulants (DOAC) or high-dose low molecular weight heparin (LMWH).
- Active menstruation or pregnancy.
- Cancer with or without metastases.
- Haemorrhagic or diabetic retinopathy.
- Presence of an abdominal or thoracic aortic aneurysm.
- Recent invasive or surgical procedure (within the past 3 weeks).
Side Effects
- Bleeding – the most common and serious complication.
- Anaphylaxis – rare, but can occur with agents like streptokinase.
- Angioedema – particularly in patients on ACE inhibitors.
Management of Life-Threatening Bleeding Due to Thrombolysis
- Administer IV fluids and packed red blood cells as necessary.
- Start with 10 units of cryoprecipitate and check fibrinogen levels.
- If fibrinogen is <1 g/L, administer an additional 10 units of cryoprecipitate.
- If bleeding persists despite a fibrinogen level >1 g/L, or if fibrinogen remains <1 g/L after 20 units of cryoprecipitate, administer 2 units of fresh frozen plasma (FFP).
- Consider administering platelets or antifibrinolytics (aminocaproic acid or tranexamic acid) if bleeding continues.
Management Options