Thrombolytics for STEMI

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

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

See Also

• STEMI
• Thrombolytics