Is thrombolysis with streptokinase (Streptokinase) or alteplase (Alteplase) indicated in a patient with ST-Elevation Myocardial Infarction (STEMI) and hypotension, without access to a Cardiac Catheterization (Cath) lab?

Thrombolysis in STEMI with Cardiogenic Shock

In a 55-year-old STEMI patient presenting with systolic blood pressure of 70 mmHg (cardiogenic shock) without cath lab access, fibrinolytic therapy is indicated and should be administered immediately, followed by urgent transfer to a PCI-capable center for emergency angiography and rescue PCI. 1

Critical Decision Framework

Immediate Reperfusion is Mandatory

• Reperfusion therapy is indicated in all STEMI patients with symptoms <12 hours duration and persistent ST-elevation, regardless of hemodynamic status 1
• When primary PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolytic therapy is recommended within 12 hours of symptom onset in patients without contraindications 1
• The presence of hypotension (SBP 70 mmHg) indicates cardiogenic shock, which is a high-risk feature requiring the most aggressive reperfusion strategy available 1

Hypotension is NOT a Contraindication

This is a critical pitfall to avoid: Hypotension from cardiogenic shock secondary to STEMI is fundamentally different from hypotension as a contraindication to thrombolysis. The contraindication refers to uncontrolled hypertension (>180/110 mmHg), not hypotension from pump failure. 1

• Cardiogenic shock patients have the highest mortality benefit from reperfusion therapy 1
• Emergency angiography and PCI is specifically recommended in patients with heart failure/shock, but when unavailable, thrombolysis becomes the only life-saving option 1

Specific Management Algorithm

Step 1: Immediate Pharmacotherapy (Within Minutes)

• Aspirin 150-325 mg orally or IV immediately 1, 2
• Clopidogrel 300 mg loading dose (given the shock state and likely need for rescue PCI) 1
• Fibrin-specific thrombolytic agent preferred: Alteplase, tenecteplase, or reteplase over streptokinase 1, 2
  • Alteplase provides significantly higher TIMI-3 flow rates (72.5%) compared to streptokinase (39.2%) 3
  • Streptokinase causes more hypotension as a complication, which is particularly problematic in this already hypotensive patient 3

Step 2: Anticoagulation

• Enoxaparin IV followed by subcutaneous (preferred over UFH) or weight-adjusted UFH bolus followed by infusion 1
• Continue anticoagulation until revascularization or for duration of hospital stay up to 8 days 1

Step 3: Hemodynamic Support

• Initiate vasopressor support (norepinephrine or dopamine) to maintain adequate perfusion pressure
• Consider intra-aortic balloon pump if available before transfer
• Avoid excessive fluid administration that could worsen pulmonary edema

Step 4: Immediate Transfer Arrangements

• Transfer to PCI-capable center must be arranged immediately after fibrinolysis initiation 1, 2
• Patient should bypass emergency department and go directly to catheterization laboratory upon arrival 1
• Emergency angiography and PCI is specifically recommended in patients with shock 1

Step 5: Post-Thrombolysis Monitoring (During Transfer)

• Assess ST-segment resolution at 60-90 minutes post-fibrinolysis 1, 2
• Rescue PCI is indicated immediately if <50% ST-segment resolution 1, 2
• Rescue PCI is also indicated at any time for hemodynamic instability, electrical instability, or worsening ischemia 1

Evidence Strength and Nuances

The 2017 ESC Guidelines provide Class I, Level A recommendations for both fibrinolytic therapy when PCI is unavailable and for emergency angiography in shock patients 1. This represents the highest level of evidence and strongest recommendation possible.

Key distinction: While primary PCI is superior to fibrinolysis in general STEMI populations, the mortality benefit of any reperfusion versus no reperfusion in cardiogenic shock is so substantial that fibrinolysis becomes lifesaving when PCI is not immediately available 1. The 2009 ACC/AHA guidelines similarly support transfer for primary PCI in high-risk patients, but when transfer time exceeds 120 minutes, fibrinolysis should not be delayed 1.

Absolute Contraindications to Screen For

Before administering thrombolytics, rapidly exclude:

• Active bleeding or bleeding diathesis
• History of intracranial hemorrhage or stroke
• Intracranial neoplasm or arteriovenous malformation
• Recent major surgery or trauma (<3 weeks)
• Suspected aortic dissection (critical in hypotensive patients)

Age 55 years is not a contraindication; increased bleeding risk primarily affects patients ≥75 years 4

Post-Fibrinolysis Expectations

• If successful (≥50% ST-resolution), angiography and PCI should occur between 2-24 hours 1, 2
• Given the shock state, this patient will likely require emergency angiography regardless of ST-resolution 1
• Major bleeding occurs in approximately 7% of patients with both alteplase and streptokinase 3