thrombolysis for acute myocardial infarction
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Indications
- ST segment elevation myocardial infarction (STEMI)
- within 6-12 hours of onset of symptoms of STEMI
- acute coronary syndrome with new left bundle branch block
- PCI indicated, but cannot be facilitated within 2 hours[2]
* age < 76 years[4]
Contraindications
- absolute
- previous hemorrhagic stroke at any time
- history of ischemic stroke within last 3 months
- known cerebrovascular lesion: intracranial tumor, AV malformation
- active internal bleeding or bleeding diathesis
- excludes menses
- suspected aortic dissection
- closed head trauma or facial trauma within 3 months[2]
- relative
- history of remote stroke (> 3 months prior), dementia or cerebral pathology
- history of recent transient ischemic attacks
- prolonged (> 10 min) or traumatic cardiopulmonary resuscitation (CPR) or major surgery (< 3 weeks)
- recent (within 2-4 weeks) internal bleeding
- active peptic ulcer disease
- hemorrhagic diabetic retinopathy
- pregnancy
- major trauma or surgery within 2 weeks[2] (6 weeks-3 months[7])
- active peptic ulcer disease
- concurrent warfarin therapy[2]
- puncture of a non-compressible vessel
- severe uncontrolled hypertension;
- blood pressure > 180/110 on presentation[2]
- history of chronic, severe, uncontrolled hypertension[2]
- for streptokinase/anistreplase: prior exposure (> 5 days) or prior allergic reaction
- PCI is indicated for STEMI, ACS with LBBB, posterior wall MI if transfer can be facilitated within 2 hours of hospital arrival[2]
- not indicated for non-STEMI
* any condition pre-disposing to major bleeding complications
Benefit/risk
- number needed to treat (NNT)
- number need to harm
- 143 for major hemorrhage
- 250 for hemorrhagic stroke[11]
Laboratory
- reperfusion is associated with higher peak CK-MB levels than persistent occlusion
Clinical significance
- thrombolytic therapy within 6 hours of symptom onset in the setting of an acute myocardial infarction (MI) reduces short-term mortality by 25%
- survival benefit is less after 6 hours, but still present for as many as 12 hours after symptom onset.
- patients with anterior wall MIs have the greatest survival benefit
Procedure
- Agents:
- recombinant tissue plasminogen activator (TPA)
- alteplase, reteplase, tenecteplase
- short thrombolytic time
- adjunct heparin therapy for the 1st 24 hours
- 100 mg over 90 minutes
- LMW heparin may be preferable[8]
- streptokinase
- long thrombolytic time of 16 hours
- do not use adjunct heparin therapy
- 250,000 unit bolus, then 1.5 x 10E6 over 1 hour
- anistreplase (APSAC)
- 30 units IV over 2-5 minutes
- recombinant tissue plasminogen activator (TPA)
- Adjunctive agents:
- aspirin 325 mg is used during initial contact
- clopidogrel 300 mg PO improves outcome[2]
- more widely studied than pasugrel or ticagrelor in patients undergoing reperfusion for STEMI[2]
Complications
- stroke
- incidence 1.2%
- most commonly hemorrhagic stroke (0.7%)
- generally occur within 24-36 hours
- risk factors
- age > 65 years
- female
- body weight < 70 kg (154 lbs)
- diastolic hypertension (> 110 mm Hg)
- wide pulse pressure
- use of tissue plasminogen activator (TPA)
- diabetes mellitus
- previous or current anticoagulation
- systemic bleeding
- intravascular procedures (i.e. cardiac catheterization)
- anticoagulation
- incidence > 5%
- increased risk for women (1.7-2.5) vs men[10]
- hypotension (reversible) with streptokinase
- thrombolytic therapy increases markers of myocardial infarction.
- increased incidence of arrhythmias
- increased risk of death for women (1.5-2.2 fold) vs men[10]
Management
- transfer to a PCI-capable facility after thrombolytic therapy[2]
- PCI indicated after failed fibrinolysis[2][12][13]
More general terms
Additional terms
- fibrinolytic agent (thrombolytic agent)
- myocardial infarction (MI); heart attack
- PTCA/PCI vs thrombolysis for acute MI
- reperfusion-eligible acute myocardial infarction
References
- ↑ nlmpubs.nlm.nih.gov/hstat/ahcpr/
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 17. American College of Physicians, Philadelphia 1998, 2006, 2009, 2015
- ↑ The Guide to Cardiology, 3rd edition, RA Kloner (editor), LeJacq communications, Greenwich Connecticut, 1995, pg 277-288 American Heart Association and American College of Clinical Cardiology
- ↑ 4.0 4.1 Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 94
- ↑ Gurwitz & Goldberg JAMA 277:1723, 1997
- ↑ Krumholz et al JAMA 277:1683, 1997
- ↑ 7.0 7.1 UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- ↑ 8.0 8.1 Journal Watch 25(5):438-39, 2005 Yusuf S, Mehta SR, Xie C, Ahmed RJ, Xavier D, Pais P, Zhu J, Liu L; CREATE Trial Group Investigators. Effects of reviparin, a low-molecular-weight heparin, on mortality, reinfarction, and strokes in patients with acute myocardial infarction presenting with ST-segment elevation. JAMA. 2005 Jan 26;293(4):427-35. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15671427
- ↑ Journal Watch 25(8):57, 2005 Sabatine MS, Cannon CP, Gibson CM, Lopez-Sendon JL, Montalescot G, Theroux P, Claeys MJ, Cools F, Hill KA, Skene AM, McCabe CH, Braunwald E; CLARITY-TIMI 28 Investigators. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005 Mar 24;352(12):1179-89. Epub 2005 Mar 9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15758000 Lange RA, Hillis LD. Concurrent antiplatelet and fibrinolytic therapy. N Engl J Med. 2005 Mar 24;352(12):1248-50. Epub 2005 Mar 9. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15758001
- ↑ 10.0 10.1 10.2 Reynolds HR, Farkouh ME, Lincoff AM, Hsu A, Swahn E, Sadowski ZP, White JA, Topol EJ, Hochman JS; GUSTO V Investigators. Impact of female sex on death and bleeding after fibrinolytic treatment of myocardial infarction in GUSTO V. Arch Intern Med. 2007 Oct 22;167(19):2054-60. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17954798
- ↑ 11.0 11.1 11.2 11.3 11.4 The NNT: Thrombolytics Given for Major Heart Attack (STEMI) http://www.thennt.com/nnt/thrombolytics-for-major-heart-attack/
- ↑ 12.0 12.1 Sutton AG, Campbell PG, Graham R et al A randomized trial of rescue angioplasty versus a conservative approach for failed fibrinolysis in ST-segment elevation myocardial infarction: the Middlesbrough Early Revascularization to Limit INfarction (MERLIN) trial. J Am Coll Cardiol. 2004 Jul 21;44(2):287-96. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15261920
- ↑ 13.0 13.1 Gershlick AH, Stephens-Lloyd A, Hughes S, Abrams KR, Stevens SE, Uren NG, de Belder A, Davis J, Pitt M, Banning A, Baumbach A, Shiu MF, Schofield P, Dawkins KD, Henderson RA, Oldroyd KG, Wilcox R; REACT Trial Investigators. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med. 2005 Dec 29;353(26):2758-68. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16382062