II. Mechanism
- Activates plasminogen to form plasmin
- Plasmin digests Fibrin and dissolves clot
III. Indications
-
Myocardial Infarction Protocol
- Symptoms present for under 12 hours
-
ST Segment Elevation
- Two anatomically contiguous leads
- Elevation > 0.1 mV (1 mm when EKG 10 mm/1 mV)
- Under Age 75 (no absolute age cut-off)
- Absence of other disease to explain symptoms
- Ischemic Cerebrovascular Accident
- See Ischemic CVA Management
IV. Efficacy
-
Myocardial Infarction mortality
- Reduced 25% if Thrombolytic given in first 6 hours
- Thrombolytics are 75% effective revascularization
V. Contraindications: Absolute
- Active Internal Bleeding
- Suspect Aortic Dissection
- Known Traumatic Cardiopulmonary Resuscitation (CPR)
- Severe Hypertension despite Medication (>180/110)
- Major Intracranial Events
- Recent Head Trauma or intracranial neoplasm
- Known Arteriovenous Malformation or aneurysm
- Intracranial Hemorrhage on CT (CVA protocol)
- High suspicion SAH despite normal CT (CVA protocol)
- Cerebrovascular Accident (or TIA) in last 6 months
- Major surgery within last 14 days
- Highest risk surgeries for post-op bleeding: Brain or Spine Surgery
- Risk of major Hemorrhage within 1 week of surgery: 50%
- Risk of major Hemorrhage within 1-2 weeks of surgery: 20%
- Pregnancy
- Risk of bleeding 2.6%
- Consider in life-threatening massive Pulmonary Embolism if not near term
- Gartman (2013) Obstet Med 6:105-11 [PubMed]
VI. Contraindications: Relative
- Recent Trauma or major surgery in last 2 months
- Initial presenting BP > 180/110, but controlled now
- Peptic Ulcer Disease
- Remote history of Cerebrovascular Accident
- Known Bleeding Disorder
- Renal disease
- Prolonged Cardiopulmonary Resuscitation (CPR)
- Streptokinase in last 6 months
VII. Medications
- Non-clot selective Thrombolytic agents
- Streptokinase
- Urokinase
- AniStreplase (anisoylated plasminogen Streptokinase)
- STAR (Recombinant Staphylokinase)
- Clot-Specific Thrombolytic agents (bind Fibrin and then activate plasminogen to plasmin)
- Recombinant Urokinase plasminogen activator (uPA)
- Tissue Plasminogen Activator (tPA)
- Serine protease binds Fibrin and activates Fibrin-bound plasminogen to plasmin
- Plasmin breaks down both Fibrin and Fibrinogen to Fibrin
- Fibrin Degradation Products result, which in turn also act to inhibit Fibrin formation
- tPA has been replaced by recombinant products (r-tPA)
- tPA was originally synthesized and extracted from cultured mammalian cells
- Recombinant Tissue Plasminogen Activator (r-tPA)
- Alteplase (Activase)
- Reteplase (Retavase)
- Tenecteplase (TNKase, TNK tPA)
- Adjunctive Heparin (in acute Myocardial Infarction)
- Used in combination with Thrombolytic
- Contraindications to adjunctive Heparin
- Discharge from major surgery with prior 14 days
- History of Cerebrovascular Accident
- Chronic Atrial Fibrillation
- Chronic Mitral Stenosis
- Acute Gastrointestinal Hemorrhage
- Cases where adjunctive Heparin is most beneficial
- Acute anterior Myocardial Infarction
- Left ventricular thrombus by Echocardiogram
VIII. Adverse Effects
- Bleeding
- Rescue agents for Thrombolytic-related life threatening bleeding (e.g. Intracranial Hemorrhage)
- See Emergent Reversal of Anticoagulation
- Not reduced by clot-specific agents
- Consider infusing Fibrinogen Concentrate or Cryoprecipitate 10 pack
- Consider Fresh Frozen Plasma
- Consider Tranexamic Acid (TXA)
- Swaminathan and Weingart in Herbert (2020) EMRap 20(4):5-6
- Overall bleeding (Incidence: 20-25%)
- Occurs at catheter puncture sites most often
- Major bleeding (Incidence: 5-10%)
- Gastrointestinal Tract
- Retroperitoneum
- Intracranial Hemorrhage (1-2% of cases)
- Occurs more often with bolus than with infusion
- Rescue agents for Thrombolytic-related life threatening bleeding (e.g. Intracranial Hemorrhage)
- Acute Myocardial Infarction specific effects
- Reperfusion Chest Pain
- Reperfusion Arrhythmia
- Accelerated Idioventricular Rhythm
- Sinus Bradycardia
- Second or third degree AV Block
- Hypotension (Streptokinase)
- Nausea and Vomiting
- Allergic Reactions or Anaphylaxis (Streptokinase)
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Related Studies
| Definition (MSH) | Fibrinolysin or agents that convert plasminogen to FIBRINOLYSIN. |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (CHV) | a drug used to dissolve blood clots |
| Definition (NCI) | Any agent capable of dissolving an existing blood clot in order to reperfuse the blocked blood vessel. |
| Definition (CSP) | fibrinolysin or agents that convert plasminogen to fibrinolysin to dissolve blood clots. |
| Concepts | Pharmacologic Substance (T121) |
| MSH | D005343 |
| SnomedCT | 44699004, 319809004, 372742009, 303960004 |
| LNC | LP34628-5 |
| English | Fibrinolytic Agents, Thrombolytic Agents, fibrinolytic agent, Fibrinolytic Drugs, Thrombolytic Drugs, Fibrinolytic drugs, THROMBOLYTICS, thrombolytics (medication), hematological agents thrombolytics, thrombolytics, [BL115] THROMBOLYTICS, thrombolytic drug, fibrinolytic drugs, thrombolytic, thrombolytic drugs, thrombolytic agents, fibrinolytic agents, Antithrombotic Agent, Thrombolytic agent (product), Fibrinolytic drugs (product), Fibrinolytic agents, Thrombolytic agent (substance), Thrombolytic agent, Thrombolytic, Thrombolytic (product), Fibrinolytic agent, thrombolytic agent, Fibrinolytic agent, NOS, Thrombolytic agent, NOS, Fibrinolytic drugs (substance), Thrombolytic (substance), Thrombolytic Agent |
| German | Fibrinolytische Medikamente, Thrombolytische Medikamente, Fibrinolytika, Thrombolytische Mittel |
| French | Agents thrombolytiques, Agents fibrinolytiques, Médicaments fibrinolytiques, Médicaments thrombolytiques, Thrombolytiques, Fibrinolytiques |
| Swedish | Fibrinolytika |
| Czech | thrombolytika, fibrinolytika |
| Finnish | Fibrinolyyttiset lääkkeet |
| Italian | Farmaci trombolitici, Farmaci fibrinolitici, Fibrinolitici |
| Russian | ANTITROMBINOVYE SREDSTVA, TROMBOLITICHESKIE SREDSTVA, FIBRINOLITICHESKIE SREDSTVA, АНТИТРОМБИНОВЫЕ СРЕДСТВА, ТРОМБОЛИТИЧЕСКИЕ СРЕДСТВА, ФИБРИНОЛИТИЧЕСКИЕ СРЕДСТВА |
| Croatian | FIBRINOLITICI |
| Polish | Środki rozpuszczające zakrzepy, Leki fibrynolityczne |
| Japanese | 血栓溶解剤, 抗血栓剤, フィブリン溶解物質, 抗血栓症薬, 線溶物質, 線維素溶解物質, 線維素溶解薬, 血栓溶解薬, 抗血栓薬 |
| Spanish | Fibrinolíticos, agente fibrinolítico, agente trombolítico (producto), fármacos fibrinolíticos, fármacos fibrinolíticos (producto), Agentes Antitrombóticos, Agentes Fibrinolíticos, Agentes Trombolíticos, agente trombolítico (sustancia), agente trombolítico, trombolítico (sustancia), trombolítico (producto), trombolítico, Trombolíticos |
| Portuguese | Agentes Antitrombóticos, Agentes Fibrinolíticos, Agentes Trombolíticos, Fibrinolíticos, Trombolíticos |
Ontology: Thrombolysis, function (C0520997)
| Definition (NCI_NCI-GLOSS) | The process of breaking up a thrombus (blood clot) that is blocking blood flow. The blood clot may be dissolved using drugs delivered through a catheter (tube) into the clot. |
| Definition (NCI) | The process of breaking up and dissolving blood clots. |
| Concepts | Clinical Attribute (T201) |
| SnomedCT | 51308000 |
| Italian | Trombolisi |
| Japanese | 血栓溶解, ｹｯｾﾝﾖｳｶｲ |
| English | Thrombolytic, Thrombolysis, function, thrombolysis, Thrombolysis, Thrombolysis, function (observable entity), Thrombolysis, NOS, Thrombolysis (function) |
| Czech | Trombolýza |
| Hungarian | Thrombolysis |
| Spanish | disolución de un trombo, tromboclasia, trombólisis (entidad observable), trombólisis (función), trombólisis, Trombolisis |
| Portuguese | Trombólise |
| Dutch | trombolyse |
| French | Thrombolyse |
| German | Thrombolyse |
