Is anticoagulation given to patients undergoing primary fibrinolysis?

Anticoagulation is Required During and After Primary Fibrinolysis

Anticoagulation is strongly recommended in patients treated with fibrinolytic therapy until revascularization (if performed) or for the duration of hospital stay up to 8 days. 1

Anticoagulation Protocol with Fibrinolysis

When fibrinolysis is chosen as the reperfusion strategy for STEMI patients, anticoagulation must be administered alongside fibrinolytic therapy to maximize efficacy and reduce complications.

Recommended Anticoagulants:

1. Preferred option: Enoxaparin

   • Initial IV bolus followed by subcutaneous dosing 1
   • Superior to unfractionated heparin in preventing recurrent thrombotic events 1

2. Alternative option: Unfractionated heparin (UFH)

   • Weight-adjusted IV bolus followed by infusion 1
   • Titrated to achieve appropriate aPTT levels

3. For streptokinase only: Fondaparinux

   • IV bolus followed by subcutaneous dose 24 hours later 1
   • Note: Fondaparinux is NOT recommended for primary PCI 1

Duration of Anticoagulation:

• Continue until revascularization is performed, or
• For the duration of hospital stay up to 8 days 1

Antithrombotic Co-therapy

Anticoagulation must be combined with antiplatelet therapy:

• Aspirin: Oral or IV administration is indicated for all patients 1
• Clopidogrel: Must be added to aspirin in all patients receiving fibrinolysis 1
• DAPT duration: Up to 12 months in patients undergoing fibrinolysis followed by PCI 1

Post-Fibrinolysis Management

The 2017 ESC guidelines recommend a systematic approach after fibrinolysis:

1. Transfer to PCI-capable center: Immediate transfer is indicated for all patients after fibrinolysis 1

2. Timing of angiography:

   • Emergency angiography for patients with heart failure/shock 1
   • Immediate rescue PCI if fibrinolysis fails (<50% ST-segment resolution at 60-90 min) 1
   • Routine angiography between 2-24 hours after successful fibrinolysis 1
   • Emergency angiography if recurrent ischemia or reocclusion occurs 1

Common Pitfalls to Avoid

1. Inadequate anticoagulation: Failing to provide anticoagulation during fibrinolysis significantly increases the risk of reocclusion and treatment failure.

2. Inappropriate anticoagulant selection: Using fondaparinux in primary PCI is contraindicated 1.

3. Delayed transfer: All patients should be transferred to a PCI-capable center immediately after fibrinolysis, not waiting to see if reperfusion is successful 1.

4. Missing reperfusion failure: Rescue PCI should be performed immediately if there is <50% ST-segment resolution at 60-90 minutes, indicating failed fibrinolysis 1.

5. Anticoagulation intensity: During ultrasound-assisted catheter-directed thrombolysis, lower levels of anticoagulation are used during fibrinolytic administration, with therapeutic doses resumed after completion 2.

Conclusion

Anticoagulation is an essential component of fibrinolytic therapy for STEMI patients. The evidence strongly supports the use of anticoagulants during and after fibrinolysis to prevent reocclusion, with enoxaparin being the preferred agent. All patients should be transferred to a PCI-capable center after fibrinolysis for potential intervention based on clinical status and response to fibrinolytic therapy.