What are the contraindications for thrombolysis?

Contraindications for Thrombolysis

Thrombolytic therapy is absolutely contraindicated in patients with active internal bleeding, history of hemorrhagic stroke, recent cranial trauma or neoplasms, blood pressure >200/120 mmHg, and diabetic hemorrhagic retinopathy. 1

Absolute Contraindications

• Active internal bleeding 1
• History of hemorrhagic stroke or stroke of unknown origin at any time 1
• Ischemic stroke within the preceding 6 months 1
• Central nervous system damage or neoplasms 1
• Recent major trauma, surgery, or head injury (within preceding 3 weeks) 1
• Gastrointestinal bleeding within the last month 1
• Known active bleeding disorder 1
• Diabetic hemorrhagic retinopathy 1

Relative Contraindications

• Transient ischemic attack in preceding 6 months 1
• Current oral anticoagulant therapy 1
• Pregnancy or within 1 week postpartum 1
• Non-compressible vascular punctures 1
• Traumatic cardiopulmonary resuscitation 1
• Refractory hypertension (systolic blood pressure >180 mmHg) 1
• Advanced liver disease 1
• Infective endocarditis 1
• Active peptic ulcer 1
• Recent (within 10 days) gastrointestinal bleeding 1
• Large thrombus in left atrium or on prosthesis 1
• Known bleeding diathesis 1
• Previous exposure to streptokinase or APSAC (contraindication to reuse any streptokinase-containing agent) 2, 1
• Uncontrolled severe hypertension 2, 1

Special Considerations

Risk-Benefit Assessment in Life-Threatening Situations

• In high-risk pulmonary embolism with cardiogenic shock or persistent hypotension, some absolute contraindications may be reconsidered as relative, requiring individual risk-benefit assessment 2, 1
• For patients with high-risk PE and absolute contraindications to thrombolysis, surgical embolectomy is the preferred therapy 2
• If surgical embolectomy is not immediately available, catheter embolectomy or thrombus fragmentation may be considered as alternatives 2

Bleeding Risk Factors

• Vascular puncture sites (especially femoral) for procedures like pulmonary angiography increase hemorrhagic risk by up to three times 3
• Additional risk factors for bleeding complications include:
  • Uncontrolled hypertension 3
  • Concurrent use of oral anticoagulants 3
  • Low body weight 3
  • Diabetes 3
  • Female gender 3
  • Age over 70 years 3

Management of Bleeding Complications

• If major bleeding occurs during thrombolysis, immediately:
  • Discontinue thrombolytic therapy 3
  • Stop heparin administration 3
  • Consider neutralization of circulating plasmin 3
  • Correct fibrinogen deficits as needed 3

Novel Oral Anticoagulants (NOACs) and Thrombolysis

• Thrombolysis is contraindicated if a patient reports intake of NOACs without information on time of last dose 4
• For patients on vitamin K antagonists, thrombolysis may be considered if INR ≤ 1.7 4

Alternative Approaches

• In cases where standard thrombolytic dosages are contraindicated but thrombolysis is life-saving, prolonged administration of low-dose urokinase (1,000 units/kg/h) may be considered as an alternative approach 5
• For patients with prosthetic valve thrombosis and contraindications to thrombolysis, a combination of subcutaneous heparin and warfarin for approximately 3 months may help dissolve moderate amounts of residual thrombosis 2