Are there contraindications to thrombolytic therapy?

Absolute contraindications

Active bleeding

Puncture of a noncompressible vessel Possible aortic dissection Active intracranial malignancy Recent major surgery (1 wk)

Acute pericarditis

Previous drug allergy (to streptokinase or APSAC)

Relative contraindications

Major trauma or surgery in last 6-8 wks Recent stroke or brain tumor Prolonged cardiopulmonary resuscitation History of peptic ulcer disease Diabetic retinopathy

Severe uncontrolled hypertension Pregnancy

History of bleeding diathesis Cancer

Severe hepatic dysfunction

What are the possible complications?

Both minor and major complications with thrombolytic therapy have been reported. Allergic reactions have been described with streptokinase and APSAC secondary to streptokinase antibodies. Hypotension is more frequent with streptokinase than tPA. The major complications of thrombolytic therapy are directly related to impairment of hemostasis and are far more common in the presence of a vascular procedure. In the absence of a vascular procedure, major bleeding occurs in 0.1-0.3% of patients and hemorrhagic cerebral infarctions occur in up to 0.6%.

How do you reverse thrombolytic therapy?

Bleeding complications occur in 5% of patients receiving thrombolytic therapy and may be divided into major and minor events. Intracranial bleeding is the most severe and occurs in 0.2-0.6% of cases, with a 50-75% mortality. Fortunately, 70% of all bleeding complications occur at the site of an invasive procedure and can be controlled locally. Treatment of bleeding complications should be tailored to the individual.

In the initial evaluation of the bleeding patient, all vascular sites should be inspected and pressure applied as needed. Blood should be sent for crossmatch testing. Heparin and any antiplatelet drugs therapies should be discontinued. If necessary, protamine may be given to reverse the heparin effect (1 mg protamine/100 U heparin not to exceed 50 mg in 10 min). For severe bleeding, cryoprecipitate and fresh frozen plasma should be given, especially if the fibrinogen level is 100 mg/dL. Platelets can be given when the bleeding time is prolonged. If life-threatening bleeding continues, antifibrinolytic drugs may be considered.

What are the indications for primary and secondary use of percutaenous transluminal coronary angioplasty (PTCA)?

Indications for the use of PTCA in myocardial infarction are evolving. At present, PTCA should be considered in patients with contraindications to thrombolytic therapy, when lytic therapy has failed, and in high-risk patients (age 70 years, anterior myocardial infarction, persistent sinus tachycardia, or cardiogenic shock).

Primary PTCA for myocardial infarction has been demonstrated to be safe and effective. Patency rates exceed 90%, and lower rates of serious bleeding, recurrent ischemia, and death have been reported compared to thrombolytic therapy in high-risk patients. However, primary PTCA should be considered instead of thrombolytic therapy only if it can be performed quickly. Unfortunately, at present only 18% of U.S. hospitals can perform PTCA, and surgical back-up should be available in case of emergency. The overall goal in patients with myocardial infarction is safe, prompt restoration of antegrade flow in the occluded artery with whatever method is available. There is no role for early and routine PTCA in patients who have received successful thrombolytic therapy.

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