What is the management of thrombolysis for myocardial infarction (MI)?

From the Guidelines

Thrombolysis should be administered to patients with STEMI when primary PCI cannot be performed within 120 minutes of first medical contact, ideally within 30 minutes of hospital arrival, as it improves survival and preserves cardiac function 1.

Indications for Thrombolysis

• STEMI patients at non-PCI-capable hospitals when the anticipated FMC-to-device time at a PCI-capable hospital exceeds 120 minutes
• STEMI patients with onset of ischemic symptoms within the previous 12 hours when primary PCI cannot be performed within 120 minutes of FMC
• STEMI patients with cardiogenic shock who are unsuitable candidates for either PCI or CABG

Administration of Thrombolysis

• The primary fibrinolytic agent used is alteplase (tPA) at 100 mg IV over 90 minutes, with 15 mg given as an initial bolus, followed by 50 mg over 30 minutes, then 35 mg over 60 minutes
• Alternative options include reteplase (10 units IV given twice, 30 minutes apart) or tenecteplase (single weight-based IV bolus of 30-50 mg)
• Patients should receive aspirin 325 mg and often clopidogrel 300 mg (75 mg for patients >75 years) before administration

Contraindications for Thrombolysis

• Active bleeding
• Recent stroke
• Head trauma
• Major surgery
• Uncontrolled hypertension

Importance of Timely Reperfusion

• Time from symptom onset to reperfusion is an important predictor of patient outcome
• Mortality increases significantly with each 15-minute delay in the time between arrival and restoration of TIMI-3 flow (door-to–TIMI-3 flow time) 1
• The medical contact–to-balloon or door-to-balloon time goal should be within 90 minutes to maximize the benefits for reperfusion by PCI 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Thrombolysis in Myocardial Infarction

• Thrombolysis is a treatment option for patients with ST-elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) is not possible within 120 minutes of first medical contact (FMC) 2.
• The American College of Chest Physicians recommends the administration of streptokinase, anistreplase, alteplase, reteplase, or tenecteplase over no fibrinolytic therapy for patients with ischemic symptoms characteristic of acute MI of ≤ 12 h in duration and persistent STE 3.
• Fibrinolysis therapy should be administered to dissolve the occluding thrombus if PCI cannot be performed within 120 minutes of STEMI diagnosis 4.
• Thrombolysis is not the final therapy, and cardiac catheterization with PCI should be performed within 24 hours (but not before 3 hours) after thrombolysis 2.

Timing and Administration of Thrombolysis

• The time delay between the onset of symptoms and the first medical contact (FMC) and the time delay between FMC and the beginning of reperfusion therapy are critical in determining the outcome of STEMI patients 2.
• Thrombolysis should be initiated within 30 minutes after FMC, either in the EMS ambulance or in a nearby non-PCI hospital 2.
• The choice of thrombolytic agent and the timing of administration depend on various factors, including the patient's symptoms, medical history, and the availability of PCI facilities 3.

Combination Therapy with Thrombolysis

• Dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine is recommended for patients with STEMI, including those undergoing thrombolysis 2, 3.
• Anticoagulation therapy, such as unfractionated heparin (UFH) or bivalirudin, is also recommended for patients with STEMI, including those undergoing thrombolysis 2, 3.