Acute Coronary Syndrome: Cardiac Thrombolysis
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.
