Is tissue plasminogen activator (tPA) contraindicated in?

From the Guidelines

Tissue plasminogen activator (tPA) is contraindicated in patients with active internal bleeding, intracranial hemorrhage, recent stroke within 3 months, severe head trauma within 3 months, intracranial or intraspinal surgery within 3 months, and known arteriovenous malformation or aneurysm, as stated in the guidelines for the early management of patients with acute ischemic stroke 1.

Key Contraindications

• Active internal bleeding
• Intracranial hemorrhage
• Recent stroke within 3 months
• Severe head trauma within 3 months
• Intracranial or intraspinal surgery within 3 months
• Known arteriovenous malformation or aneurysm
• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
• Acute bleeding diathesis, including but not limited to platelet count <100,000/mm³
• Current use of anticoagulant with INR >1.7 or PT >15 seconds

Relative Contraindications

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Pregnancy
• Seizure at onset with postictal residual neurological impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)

These contraindications exist because tPA works by breaking down blood clots, which can lead to uncontrolled bleeding in high-risk patients, as noted in the guidelines 1. Always perform a thorough assessment of bleeding risk before administering tPA, considering the patient's individual risk factors and medical history.

From the FDA Drug Label

Cathflo Activase should not be administered to patients with known hypersensitivity to Alteplase or any component of the formulation

• Known hypersensitivity to Alteplase or any component of the formulation is a contraindication for tPA (IV) 2

From the Research

Tissue Plasminogen Activator (tPA) Contraindications

• The use of tPA is contraindicated in certain conditions due to the risk of bleeding complications, including intracranial hemorrhage 3.
• However, a history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy with tPA, as it does not increase the risk of symptomatic intracerebral hemorrhage (SICH) or mortality rates in patients with a history of cerebral hemorrhage 4.
• Other potential contraindications for tPA include:
  • Uncontrolled hypertension 3, 5
  • Combination antiplatelet use 5
  • Large areas of early ischemic change 5
  • Atrial fibrillation 5
  • Congestive heart failure 5
  • Leukoariosis 5
• The use of tPA in patients with high bleeding risk, such as those with massive pulmonary embolism, may require a reduced dose to minimize the risk of bleeding complications 6.
• Novel strategies, such as risk assessment scores, novel imaging strategies, and telemedicine, may help optimize the risk-benefit ratio of tPA therapy 7, 5.