EMConference: Thrombolytics in STEMI


  • In the absence of contraindications, should be given to STEMI patients with symptoms <12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC (class I) 

  • Up to 12-24 hours of symptoms with STEMI when PCI unavailable (class IIa) 


When to choose lytics? 

  • Non-PCI capable hospital and the total time it would take to transfer to a PCI-capable hospital and FMC–device time is > 120 min away 

  • Ideally within the first 30 min  

  • Up until 12 – 24 hours in some cases 


Agents in MI:

  • tPA: 15 mg IV over 1-2 min followed by 50 mg IV over 30 min followed by 35 mg IV over 60 min (total 100 mg over 1.5 hours) 

  • TNKase: 30-50 mg IV over 5 sec (dosing is weight based) 

  • rPA: 10 Units x 2 given 30 min apart 


Absolute contraindications:

  • Any prior ICH 

  • Ischemic stroke within 3 months (except acute ischemic stroke w/in 4.5 hrs) 

  • Known structural cerebral vascular lesion (e.g. AVM) or intracranial neoplasm (primary or metastatic) 

  • Active bleeding or bleeding diatheses (excluding menses) 

  • Intracranial or intraspinal surgery within 2 months 

  • For streptokinase, prior tx within the previous 6 months 

  • Significant closed-head or facial trauma within 3 months 

  • Suspected aortic dissection 

  • Severe uncontrolled HTN (unresponsive to emergency therapy) 


Adjunctive Therapies to Lytics:

  • ASA: 162 to 325 mg loading dose 

  • Clopidogrel: 300 mg for ≤75 years old / 75 mg for >75 years old 

  • UFH bolus & gtt or Enoxaparin or Fondaparinux 


Last points:

  • Transfer!  Regardless of hemodynamics or reperfusion success, it is reasonable to still get patients to a PCI-capable center. 

  • Angiography recommended within the first 24 hours but AVOIDED for the first 2-3 hours after fibrinolytic therapy.