• 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