Streptokinase Dosing for Cardiovascular Emergencies
Acute Myocardial Infarction
For acute ST-elevation myocardial infarction, administer streptokinase 1.5 million units intravenously over 30-60 minutes. 1
- This dosing regimen is recommended by the European Society of Cardiology when primary PCI cannot be performed within 120 minutes of first medical contact 1
- The infusion should ideally be initiated within 30 minutes of first medical contact (door-to-needle time) 2
- Treatment is most effective when given within 12 hours of symptom onset, with greatest benefit occurring with earlier administration 2
- The 30-minute infusion may achieve faster reperfusion compared to 60-minute infusion, though both are acceptable 3
Critical Adjunctive Therapy
Aspirin must be administered concurrently: 150-300 mg chewed or 250 mg IV if oral ingestion is not possible, followed by 75-100 mg daily 2, 1
Clopidogrel should be added: 300 mg loading dose orally (if age ≤75 years), followed by 75 mg daily maintenance 1
Anticoagulation is mandatory until revascularization or for hospital stay duration up to 8 days 2, 1:
- Fondaparinux is preferred with streptokinase: 2.5 mg IV bolus followed by 2.5 mg SC once daily 1
- Alternatively, unfractionated heparin: 60 U/kg IV bolus (maximum 4000 U) followed by 12 U/kg/hr infusion (maximum 1000 U/hr) for 24-48 hours, targeting aPTT 50-70 seconds 1
- Enoxaparin option: For patients <75 years, 30 mg IV bolus followed by 1 mg/kg SC every 12 hours; for patients ≥75 years, no IV bolus with first SC dose of 0.75 mg/kg 1
Acute Pulmonary Embolism
For massive pulmonary embolism, administer streptokinase 1.5 million units intravenously over 1 hour. 4
- This high-dose, short-term regimen has demonstrated efficacy in reversing acute pulmonary arterial hypertension and right ventricular dysfunction without increasing hemorrhagic complications 4
- The regimen is particularly effective in properly selected high-risk PE patients with evidence of right ventricular dysfunction 4
- Treatment should be initiated as early as possible, ideally within 6 hours of symptom onset, as delays beyond this timeframe increase mortality risk 4
Acute Ischemic Stroke
Streptokinase is NOT recommended for acute ischemic stroke. The FDA-approved agent for this indication is alteplase (tissue plasminogen activator), not streptokinase 5
- The recommended dose for acute ischemic stroke is alteplase 0.9 mg/kg (maximum 90 mg) infused over 60 minutes with 10% as initial bolus 5
- Streptokinase lacks evidence and regulatory approval for stroke treatment
Important Safety Considerations
Absolute Contraindications 2
- Previous intracranial hemorrhage or stroke of unknown origin
- Ischemic stroke in preceding 6 months
- Central nervous system damage, neoplasms, or arteriovenous malformation
- Recent major trauma/surgery/head injury (within 3 weeks)
- Gastrointestinal bleeding within past month
- Known bleeding disorder
- Aortic dissection
- Non-compressible punctures in past 24 hours
Critical Warnings
- Never re-administer streptokinase due to antibody formation that impairs activity and increases allergic reaction risk 1
- Monitor for hypotension, which commonly occurs during streptokinase administration 1
- Intracranial hemorrhage occurs in 0.9-1.0% of patients 1
- Risk factors for intracranial hemorrhage include lower weight, female sex, previous cerebrovascular disease, and hypertension on admission 1
Post-Administration Monitoring
Monitor for successful reperfusion at 60-90 minutes 1:
- Relief of chest pain symptoms
- Reduction of ST-segment elevation by at least 50%
- Maintenance of hemodynamic and electrical stability
All patients should be transferred to a PCI-capable center following fibrinolysis 1
Angiography with view to revascularization is recommended between 3-24 hours after successful fibrinolysis 1