EMConference: Thrombolytics in STEMI
Fibrinolysis:
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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)
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Up to 12-24 hours of symptoms with STEMI when PCI unavailable (class IIa)
When to choose lytics?
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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
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Ideally within the first 30 min
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Up until 12 – 24 hours in some cases
Agents in MI:
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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)
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TNKase: 30-50 mg IV over 5 sec (dosing is weight based)
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rPA: 10 Units x 2 given 30 min apart
Absolute contraindications:
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Any prior ICH
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Ischemic stroke within 3 months (except acute ischemic stroke w/in 4.5 hrs)
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Known structural cerebral vascular lesion (e.g. AVM) or intracranial neoplasm (primary or metastatic)
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Active bleeding or bleeding diatheses (excluding menses)
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Intracranial or intraspinal surgery within 2 months
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For streptokinase, prior tx within the previous 6 months
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Significant closed-head or facial trauma within 3 months
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Suspected aortic dissection
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Severe uncontrolled HTN (unresponsive to emergency therapy)
Adjunctive Therapies to Lytics:
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ASA: 162 to 325 mg loading dose
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Clopidogrel: 300 mg for ≤75 years old / 75 mg for >75 years old
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UFH bolus & gtt or Enoxaparin or Fondaparinux
Last points:
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Transfer! Regardless of hemodynamics or reperfusion success, it is reasonable to still get patients to a PCI-capable center.
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Angiography recommended within the first 24 hours but AVOIDED for the first 2-3 hours after fibrinolytic therapy.