Is dilated cardiomyopathy (DCMP) a contraindication for intravenous (IV) thrombolysis with alteplase (tissue plasminogen activator) in a patient with stroke?

Dilated Cardiomyopathy is NOT a Contraindication for IV Thrombolysis in Stroke Patients

Dilated cardiomyopathy (DCMP) is not a contraindication for intravenous thrombolysis with alteplase in patients with acute ischemic stroke. 1

Evidence-Based Rationale

The American Heart Association guidelines specifically address cardiac conditions in relation to thrombolysis eligibility and do not list dilated cardiomyopathy as a contraindication. According to high-quality evidence:

• Low left ventricular ejection fraction (LVEF ≤30%) alone is not a contraindication for alteplase administration 1
• IV thrombolysis is recommended for eligible patients within 4.5 hours of symptom onset, regardless of underlying cardiac conditions 2, 1
• The American College of Chest Physicians strongly recommends (Grade 1A) IV thrombolysis with alteplase for patients with acute ischemic stroke within 3 hours of symptom onset 2, 3

Important Considerations for Patients with DCMP

While DCMP itself is not a contraindication, there are important considerations when administering thrombolysis to these patients:

Left Ventricular Thrombus Risk

• Patients with DCMP have higher risk of intraventricular thrombus formation due to blood stasis 4
• If LV thrombus is present, this represents a relative consideration (not absolute contraindication) for thrombolysis 1
• For patients with major stroke likely to produce severe disability, IV alteplase may still be reasonable even with LV thrombus 1

Standard Contraindications Still Apply

All standard contraindications for IV thrombolysis must still be considered:

• Intracranial hemorrhage on initial neuroimaging
• Blood pressure >185/110 mmHg despite treatment
• Recent major surgery or bleeding
• Use of anticoagulants with elevated INR
• Ischemic stroke within the last 3 months
• Severe head trauma in the last 3 months 2, 1

Treatment Algorithm for Stroke Patients with DCMP

1. Confirm eligibility for IV thrombolysis:

   • Time window: Within 4.5 hours of symptom onset
   • No absolute contraindications present
   • Blood pressure <185/110 mmHg

2. Cardiac-specific assessment:

   • Check for presence of LV thrombus (relative consideration)
   • If LV thrombus present, weigh stroke severity against bleeding risk
   • For severe strokes, consider proceeding with thrombolysis despite LV thrombus

3. Administration protocol:

   • Alteplase dose: 0.9 mg/kg (maximum 90 mg)
   • 10% as IV bolus over one minute
   • Remaining 90% as IV infusion over 60 minutes 1

4. Post-thrombolysis monitoring:

   • Neurological checks every 15 minutes for first 2 hours
   • Maintain blood pressure <180/105 mmHg
   • Monitor for signs of hemorrhagic transformation 1

Special Considerations for Time Windows

• 0-3 hours: Strongest recommendation for IV thrombolysis (Grade 1A) 2
• 3-4.5 hours: Still recommended but with additional exclusion criteria (Grade 2C) 2

• 4.5 hours: Generally not recommended unless specific imaging criteria are met 2, 5

Conclusion

Dilated cardiomyopathy itself does not contraindicate IV thrombolysis for acute ischemic stroke. The decision should be based on standard eligibility criteria, with special attention to the possible presence of left ventricular thrombus, which represents a relative consideration rather than an absolute contraindication.