Can streptokinase be given in patients with hypotension?

Streptokinase Administration in Hypotension

Streptokinase can be given in hypotension, but severe uncontrolled hypotension (systolic blood pressure <90 mmHg) is a relative contraindication to fibrinolytic therapy, and the decision requires careful risk-benefit assessment based on the underlying condition being treated. 1

Context-Dependent Recommendations

For ST-Elevation Myocardial Infarction (STEMI)

Streptokinase may be administered in patients with mild-to-moderate hypotension, as the hypotension it causes is typically transient and manageable, but caution is warranted. 1

• Relative contraindication threshold: Severe uncontrolled hypotension on presentation (SBP ≥180 mmHg or DBP ≥110 mmHg is listed as relative contraindication for hypertension; conversely, SBP <90 mmHg represents significant hypotension requiring caution) 1

• Streptokinase-specific hypotension: Administration of streptokinase is commonly associated with hypotension as a known side effect, occurring in 22% of patients in comparative studies 2

• Mechanism and timing: The hypotension typically occurs within 8-12 minutes of starting the infusion, with a mean maximum fall in systolic blood pressure of approximately 40-43 mmHg 3

• Management is straightforward: When hypotension occurs, it should be managed by temporarily halting the infusion, laying the patient flat, or elevating the feet; occasionally atropine or intravascular volume expansion may be required 1

• Transient nature: Streptokinase-induced hypotension disappears in all patients after approximately 16±6 minutes without specific therapy and has no detrimental effect on coronary reperfusion rates, cardiogenic shock incidence, or 30-day mortality 4

For Pulmonary Embolism

In patients with pulmonary embolism presenting with shock or hypotension, thrombolytic therapy (including streptokinase) is indicated as these patients have the most to gain from rapid thrombolysis. 1

• Haemodynamic and respiratory support is necessary in patients with suspected or confirmed PE presenting with shock or hypotension 1

• Thrombolytic therapy rapidly resolves thromboembolic obstruction and exerts beneficial effects on haemodynamic parameters, with approximately 92% of patients classified as responders based on clinical and echocardiographic improvement 1

For Acute Ischemic Stroke

Streptokinase should NOT be given for acute ischemic stroke, regardless of blood pressure status. 1

• Three trials of streptokinase for stroke were halted prematurely because of an excess of poor outcomes or deaths among treated patients 1

• There is no evidence that intravenous streptokinase is of benefit in patients with acute ischemic stroke 1

Practical Management Algorithm

Pre-Administration Assessment

1. Identify the indication: STEMI, pulmonary embolism, or other thromboembolic condition
2. Measure baseline blood pressure: Document systolic and diastolic values
3. Assess severity of hypotension:
   • Mild: SBP 90-100 mmHg → Proceed with caution and close monitoring
   • Moderate: SBP 80-90 mmHg → Consider if benefit outweighs risk (e.g., massive PE with shock)
   • Severe: SBP <80 mmHg → Relative contraindication; consider alternative strategies

During Administration

• Standard dosing: 1.5 million units over 30-60 minutes 1, 5
• Monitor blood pressure every 5 minutes during the first 20 minutes 5, 3
• If hypotension develops (SBP drops ≥20% or to <90 mmHg):
  • Temporarily halt or slow the infusion 1
  • Position patient flat with legs elevated 1
  • Administer IV fluids if needed 1
  • Consider atropine for bradycardia-associated hypotension 1
  • Resume infusion once blood pressure stabilizes 4

Important Caveats

• Do not use hydrocortisone routinely for prophylaxis against hypotension 1
• Never readminister streptokinase due to antibody formation that can impair activity and increase risk of allergic reactions 1
• Severe allergic reactions are rare, but hypotension is common and expected 1, 6
• The hypotension is rate-related: Slower infusion rates may reduce the severity 5
• Streptokinase-induced hypotension does not worsen outcomes when properly managed and does not increase mortality or cardiogenic shock rates 4

Alternative Considerations

If hypotension is severe or persistent, consider fibrin-specific agents (tenecteplase or alteplase) which have significantly lower rates of hypotension (5.6% vs 22.2% with streptokinase) 2, though these agents are associated with slightly higher rates of intracranial hemorrhage 1