- There is no upper age limit for this treatment
- Cardiogenic shock and ventricular arrhythmias are not contraindications to thrombolysis
INDICATIONS
- Presentation within 12 hr of onset of symptoms
- Typical cardiac chest pain persisting for >30 min
- >1 mm ST segment elevation in 2 or more precordial leads or 2 or more bipolar leads or >1 mm ST segment depression in leads V1–V3 (suggesting acute posterior infarction) or LBBB with any of the following in leads V1–V3:
- >1 mm ST segment depression
- >1 mm ST segment elevation where QRS complex positive
- >5 mm ST segment elevation where QRS complex negative
CONTRAINDICATIONS
- Absolute:
- active bleeding
- Relative:
- major trauma/major surgery within previous 4 weeks
- stroke/TIA within previous 3 months
- confirmed subarachnoid haemorrhage at any time
- traumatic cardiac massage or intracardiac injection
- known bleeding disorder
- active dyspepsia or history of GI haemorrhage
- sustained systolic BP ≥180 mmHg
- proliferative retinopathy
- recent head injury
- pericarditis
- INR >2.0
Choice of agent in the elderly (>75yr)
- In the elderly (>75 yr) not already given thrombolysis, give streptokinase 1.5 million units in 100 mL of sodium chloride 0.9% by IV infusion over 1 hr
- Streptokinase can be re-administered within 3 days of first administration but, after 5 days, the likely presence of streptokinase antibodies precludes its further use for at least 12 months
Standard agent is tenecteplase (Metalyse)
- Administer tenecteplase on the basis of body weight, with a maximum dose of 10,000 units (50 mg tenecteplase)
Choose a body weight:
- Tenectoplase: 6000 units; 30mg with corresponding volume of reconstituted solution 6 mL
- Tenectoplase: 7000 units; 35mg with corresponding volume of reconstituted solution 7 mL
- Tenectoplase: 8000 units; 40mg with corresponding volume of reconstituted solution 8 mL
- Tenectoplase: 9000 units; 45mg with corresponding volume of reconstituted solution 9 mL
- Tenectoplase: 10000 units; 50mg with corresponding volume of reconstituted solution 10 mL
- Administer by giving unfractionated heparin 5000 units by IV bolus, followed by tenecteplase administered as a single IV bolus over approximately 10 seconds, then give unfractionated heparin 1000 units/hr via infusion pump for 48 hr, adjusting dose to maintain APTT ratio 1.5–2.0
Complications
- Hypotension – if occurs de novo, review for cardiogenic shock, mitral regurgitation or tamponade. If streptokinase being administered, stop IV infusion and recommence at a slower rate after BP has recovered
- Bradycardia – usually responds to atropine 300 microgram IV
- Ventricular tachycardia or idioventricular rhythm – usually self-limiting and requires no therapy. If sustained – see Cardiac arrhythmias guideline
- Avoid arterial puncture, central venous cannulation and IM injections in patients undergoing thrombolytic therapy, unless essential to patient care
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa