Can I use Alteplase (tissue plasminogen activator) for thrombolysis in a patient with brain infarct and Left Ventricular Ejection Fraction (LVEF) of 30%?

Thrombolysis with Alteplase in Brain Infarct Patient with LVEF 30%

For patients with brain infarct and low ejection fraction (LVEF 30%), intravenous alteplase can be administered if the patient meets standard eligibility criteria for thrombolysis, as cardiac dysfunction is not a contraindication to treatment. 1, 2

Assessment of Eligibility

When considering thrombolysis in a patient with brain infarct and reduced LVEF:

1. Standard eligibility criteria apply:

   • Time window: Within 4.5 hours of symptom onset 1
   • No intracranial hemorrhage on initial neuroimaging
   • Blood pressure <185/110 mmHg
   • No recent major surgery or bleeding
   • No use of anticoagulants with elevated INR

2. Cardiac-specific considerations:

   • Low LVEF (30%) alone is not a contraindication for alteplase 1
   • Check for presence of left ventricular thrombus (relative consideration)
   • Assess for recent myocardial infarction:
     • Non-STEMI: Alteplase is reasonable 1
     • STEMI involving right or inferior myocardium: Alteplase is reasonable 1
     • STEMI involving left anterior myocardium: Alteplase may be reasonable but with higher caution 1

Administration Protocol

If the patient meets eligibility criteria:

• Administer alteplase at 0.9 mg/kg (maximum 90 mg) 1
• Give 10% (0.09 mg/kg) as intravenous bolus over one minute
• Administer remaining 90% (0.81 mg/kg) as intravenous infusion over 60 minutes 1

Monitoring and Management

For patients with low LVEF receiving alteplase:

• Monitor neurological status every 15 minutes for the first 2 hours 2
• Maintain blood pressure <180/105 mmHg after treatment 2
• Monitor cardiac status closely due to underlying cardiac dysfunction
• Be prepared to manage potential complications:
  • Symptomatic intracranial hemorrhage (risk approximately 2.4%) 2
  • Angioedema (use staged response with antihistamines, glucocorticoids) 1

Special Considerations for Low LVEF

• If known left ventricular thrombus is present:

  • For major stroke likely to produce severe disability: Treatment with IV alteplase may be reasonable 1
  • For moderate stroke likely to produce mild disability: Benefits are uncertain 1

• If acute pericarditis is present:

  • For major stroke: Treatment may be reasonable but with cardiology consultation 1
  • For moderate stroke: Benefits are uncertain 1

Evidence Quality and Considerations

The American Heart Association/American Stroke Association guidelines (2018) specifically address cardiac conditions including left ventricular thrombus and cardiac dysfunction 1. These guidelines represent the most recent and authoritative recommendations on this topic.

The benefit of alteplase in reducing disability from ischemic stroke is well-established 3, 4, with a 30% higher likelihood of minimal or no disability at 3 months compared to placebo 5. This benefit must be weighed against the small increased risk of symptomatic intracranial hemorrhage.

Conclusion

Low ejection fraction (LVEF 30%) alone should not prevent administration of alteplase in an otherwise eligible patient with acute ischemic stroke. The potential benefit of improved neurological outcomes outweighs the risks in most cases, particularly in patients with disabling deficits.