Thrombolysis/Anticoagulation Recommendations for MI/PE/Stroke

First Things First (assess for & treat the following):

Myocardial infarction (MI)

  • Appropriately used thrombolytics will:
    • Limit infarct size
    • Improve left ventricular function
    • Reduce mortality
    • Once MI confirmed, other medical diagnostics and treatment should not delay implementation of reperfusion strategy
  • Most benefit (ST-elevation MI, if percutaneous coronary intervention [PCI] not available within 90 minutes of first medical contact) if < 3 hrs from symptom onset
    • Shorter time to reperfusion leads to better outcome
    • Proven value up to 12 hrs from symptom onset
    • 12-24 hrs from symptom, fibrinlysis may be indicated if signs of continuing ischemia are present
  • Primary PCI
    • Most rapid & reliable for restoring coronary flow
    • Use instead of thrombolytics if available within 90 minutes of symptom debut

Pulmonary embolism (PE)

  • Thrombolytics appropriate for confirmed massive PE only (PE with systolic blood pressure < 90 mmHg)
  • Hemodynamic instability: hypotension with right ventricular strain
    • Modest, careful volume resuscitation: ~1 L, cautious vasoactive/inotropic support if progressive deterioration
  • Respiratory insufficiency: hypoxemia or respiratory distress
    • Oxygen therapy
    • Intubate for refractory hypoxemia or frank respiratory distress.
  • Diagnostic testing in unstable patients
    • CT angiogram to confirm massive PE
    • Consider supporting tests available in ICU/ER for decision to anticoagulate if CT not available.
      • Echocardiography
      • Lower extremity duplex ultrasound
      • CXR
      • EKG
      • D-dimer; PaO2

Stroke (acute ischemic stroke)

  • Time is critical (for patients eligible for tPA)
    • < 3 hrs from clearly defined symptom onset to IV thrombolytic administration
      • Decreased risk of death
      • Improved neuro outcome
    • 3-4.5 hrs from symptom onset, no indication for IV thrombolytics
    • >4.5 hours, strong recommendation against use of thrombolytics for ischemic stroke
    • No thrombolytics for patients with extensive stroke (>1/3 MCA territory) or clear hypodensity on CT
      • Streptokinase associated with bleeding complications in ischemic stroke, contraindicated
        • Intra-arterial thrombolytics suggested if available for middle cerebral artery occlusion, (within 6 hrs from symptom onset)
        • For confirmed acute basilar artery occlusion, IV or intra-arterial thrombolysis may be useful if available
  • Consideration for thrombolytics must begin in ER.
    • Critical pathways streamline process.

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Last updated: May 5, 2010