Absolute and Relative Contraindications for Thrombolysis in STEMI
Fibrinolytic therapy in STEMI has clearly defined absolute and relative contraindications that must be systematically assessed before administration, with absolute contraindications representing situations where the bleeding risk categorically outweighs any potential benefit. 1
Absolute Contraindications
These represent situations where thrombolysis should never be administered due to unacceptable risk of catastrophic bleeding:
Intracranial and Cerebrovascular
- Any prior intracranial hemorrhage at any time - even remote history is an absolute contraindication 2, 3, 1
- Known structural cerebral vascular lesion (e.g., arteriovenous malformation, aneurysm) 2, 3, 1
- Known malignant intracranial neoplasm (primary or metastatic) 2, 3, 1
- Ischemic stroke within 3 months - EXCEPT acute ischemic stroke within 4.5 hours of onset, where thrombolysis may be considered for the stroke itself 2, 3, 1
- Intracranial or intraspinal surgery within 2 months 1, 4
Active Bleeding and Trauma
- Active bleeding or bleeding diathesis (excluding menses) 2, 3, 1
- Significant closed-head or facial trauma within 3 months 2, 3, 1
Cardiovascular
Blood Pressure
- Severe uncontrolled hypertension unresponsive to emergency therapy (SBP >180 mm Hg or DBP >110 mm Hg) 1, 4
The 2025 ACC/AHA guidelines emphasize that this blood pressure threshold is absolute when hypertension remains unresponsive to therapy, distinguishing it from the relative contraindication of hypertension that responds to treatment. 1
Relative Contraindications
These represent situations where thrombolysis may still be considered if the benefits clearly outweigh risks, particularly in patients with large anterior STEMI or cardiogenic shock:
Hypertension
- History of chronic, severe, poorly controlled hypertension 2, 3, 1
- Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) that responds to therapy 2, 3, 1
Neurological History
- History of prior ischemic stroke >3 months ago 2, 3, 1
- Dementia 2, 3, 1
- Known intracranial pathology not covered in absolute contraindications 2, 3, 1
Recent Procedures and Trauma
- Traumatic or prolonged CPR (>10 minutes) 2, 3, 1
- Major surgery within 3 weeks 2, 3, 1
- Recent internal bleeding (within 2-4 weeks) 2, 3, 1
- Noncompressible vascular punctures 2, 3, 1
Other Medical Conditions
- Pregnancy 2, 3, 1
- Active peptic ulcer 2, 3, 1
- Current use of oral anticoagulants - the higher the INR, the higher the bleeding risk 2, 3
Agent-Specific
- For streptokinase/anistreplase only: prior exposure (>5 days ago) or prior allergic reaction to these agents 2, 3
Critical Clinical Decision Points
When Contraindications Are Present
If absolute contraindications exist, primary PCI should be performed instead of fibrinolysis. 3 The 2004 ACC/AHA guidelines specifically state that STEMI patients at substantial (≥4%) risk of intracranial hemorrhage should be treated with PCI rather than fibrinolytic therapy. 3
Time-Dependent Considerations
The distinction between absolute and relative contraindications can become critical in time-sensitive situations. For patients presenting within 3 hours of symptom onset with no access to timely PCI (<2 hours to device activation), fibrinolysis may be considered even with some relative contraindications if the area of myocardium at risk is large. 1
Common Pitfalls to Avoid
- Do not assume all recent strokes are contraindications - acute ischemic stroke within 4.5 hours is actually an indication for thrombolysis, not a contraindication 1
- Do not confuse controlled vs. uncontrolled hypertension - hypertension that responds to emergency therapy moves from absolute to relative contraindication 1
- Do not overlook recent procedures - even "minor" procedures like liver biopsy or lumbar puncture within recent weeks are contraindications due to noncompressible puncture sites 5
Risk Stratification
The 2025 guidelines emphasize that these contraindications are "viewed as advisory for clinical decision-making and may not be all-inclusive or definitive," meaning clinical judgment must be applied, particularly when weighing relative contraindications against the mortality benefit of reperfusion in high-risk STEMI. 1