Thrombolytics for STEMI

Overview

• Fibrinolytic treatment within 3hr resulted in >30 lives saved per 1000 patients

Indications

• Chest pain >30 min but <12 hrs, not relieved by nitroglycerin
• PCI greater than 120 min away
• ECG criteria of STEMI
  • STE in 2 contiguous leads
  • Posterior STEMI
  • LBBB with Sgarbossa criteria

Contraindications

Absolute

• Any prior ICH
• Known structural cerebral vascular lesion (AVM)
• Known intracranial neoplasm
• Ischemic stroke within 3 mo
• Active internal bleeding (excluding menses)
• Suspected aortic dissection or pericarditis

Relative

• Severe uncontrolled BP (>180/110)
• History of chronic severe poorly controlled hypertension
• History of prior ischemic stroke >3 mo
• Known intracranial pathology not covered in absolute contraindications
• Current use of anticoagulants with known INR >2–3
• Known bleeding diathesis
• Recent trauma (past 2 wk)
• Prolonged CPR (>10 min)
• Major surgery (<3 wk)
• Noncompressible vascular punctures (e.g. IJ, subclavian)
• Recent internal bleeding (within 2–4 wk)
• Patients treated previously with streptokinase should not receive streptokinase a 2nd time
• Pregnancy
• Active peptic ulcer disease
• Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc)

Administration

If receive fibrinolytics also give anticoagulants for minimum of 48hr, and preferable the length of the hospitalization

Alteplase (TPA)

Dosing based on patient weight:

• 67kg: Infuse 15mg IV over 1-2min; then 50mg over 30min; then 35mg over next 60min (i.e. 100mg over 1.5hr)
• ≤67kg: Infuse 15mg IV over 1-2min; then 0.75 mg/kg (max 50mg) over 30 min; then 0.5 mg/kg over 60min (max 35 mg)

Tenecteplase (TNKase)

• Reconstitute 50 mg vial in 10 mL sterile water (5 mg/mL)
• < 60 kg = 30 mg IV push over 5 seconds
• 60-69 kg = 35 mg IV push over 5 seconds
• 70-79 kg = 40 mg IV push over 5 seconds
• 80-89 kg = 45 mg IV push over 5 seconds
• > 90 kg = 50 mg IV push over 5 seconds

Complications

• 0.5-1% of patients suffer ICH

See Also

• STEMI
• Thrombolytics