Current indications/contraindications and currently used regimens for thrombolytic therapy in acute myocardial infarction.
| * Recent evidence (ASSENT III) suggests that low molecular weight heparin may be preferable over unfractionated heparin. |
| A. Indications and contraindications |
| Indications |
| Patients with chest pain consistent with the diagnosis of acute myocardial infarction and at least 0.1 mm of ST-segment elevation in at least two contiguous ECG leads in whom treatment can be initiated within 12 hours of pain onset, provided there are no contraindications to thrombolytic therapy. |
| Contraindications |
| History of a serious bleeding tendency. |
| Recent acute internal hemorrhages. |
| Major surgery, trauma, or delivery within 10 days. |
| Traumatic cardiopulmonary resuscitation. |
| Vascular puncture in a noncompressible site. |
| Uncontrolled hypertension. |
| Previous use of streptokinase is a contraindication for its repeated administration. |
| B. Currently used regimens |
| Streptokinase and aspirin |
| Streptokinase 1.5 million U IV over 30 to 60 minutes, combined with acetylsalicylic acid (ASA) 160 to 325 mg daily started as soon as possible and continued indefinitely. |
| Alteplase and intravenous heparin* |
| Alteplase (recombinant tissue-type plasminogen activator; rt-PA) 100 mg IV over 90 minutes (15 mg bolus, 0.75 mg/kg not exceeding 50 mg over 30 minutes, and 0.5 mg/kg not exceeding 35 mg over the next hour) combined with 160 to 325 mg ASA and immediate intravenous heparin (5000 U bolus and 1000 U per hour, preferably monitored with activated partial thromboplastin time). |
| Selection of regimen |
| In GUSTO, the accelerated alteplase regimen was associated with a statistically significant lower mortality than streptokinase (6.3% vs 7.3%, p= .001) but with a slightly higher incidence (0.1%) of survival with disabling stroke. |
| The t-PA congeners (reteplase and tenecteplase) have been shown in comparative megatrials to be equivalent to alteplase but they can be administered as a double or single bolus, respectively. |
| * Recent evidence (ASSENT III) suggests that low molecular weight heparin may be preferable over unfractionated heparin. |
| A. Indications and contraindications |
| Indications |
| Patients with chest pain consistent with the diagnosis of acute myocardial infarction and at least 0.1 mm of ST-segment elevation in at least two contiguous ECG leads in whom treatment can be initiated within 12 hours of pain onset, provided there are no contraindications to thrombolytic therapy. |
| Contraindications |
| History of a serious bleeding tendency. |
| Recent acute internal hemorrhages. |
| Major surgery, trauma, or delivery within 10 days. |
| Traumatic cardiopulmonary resuscitation. |
| Vascular puncture in a noncompressible site. |
| Uncontrolled hypertension. |
| Previous use of streptokinase is a contraindication for its repeated administration. |
| B. Currently used regimens |
| Streptokinase and aspirin |
| Streptokinase 1.5 million U IV over 30 to 60 minutes, combined with acetylsalicylic acid (ASA) 160 to 325 mg daily started as soon as possible and continued indefinitely. |
| Alteplase and intravenous heparin* |
| Alteplase (recombinant tissue-type plasminogen activator; rt-PA) 100 mg IV over 90 minutes (15 mg bolus, 0.75 mg/kg not exceeding 50 mg over 30 minutes, and 0.5 mg/kg not exceeding 35 mg over the next hour) combined with 160 to 325 mg ASA and immediate intravenous heparin (5000 U bolus and 1000 U per hour, preferably monitored with activated partial thromboplastin time). |
| Selection of regimen |
| In GUSTO, the accelerated alteplase regimen was associated with a statistically significant lower mortality than streptokinase (6.3% vs 7.3%, p= .001) but with a slightly higher incidence (0.1%) of survival with disabling stroke. |
| The t-PA congeners (reteplase and tenecteplase) have been shown in comparative megatrials to be equivalent to alteplase but they can be administered as a double or single bolus, respectively. |