II. Mechanism

  1. Activates plasminogen to form plasmin
  2. Plasmin digests Fibrin and dissolves clot

III. Indications

  1. Myocardial Infarction Protocol
    1. Symptoms present for under 12 hours
    2. ST Segment Elevation
      1. Two anatomically contiguous leads
      2. Elevation > 0.1 mV (1 mm when EKG 10 mm/1 mV)
    3. Under Age 75 (no absolute age cut-off)
    4. Absence of other disease to explain symptoms
  2. Ischemic Cerebrovascular Accident
    1. See Ischemic CVA Management

IV. Efficacy

  1. Myocardial Infarction mortality
    1. Reduced 25% if Thrombolytic given in first 6 hours
  2. Thrombolytics are 75% effective revascularization

V. Contraindications: Absolute

  1. Active Internal Bleeding
  2. Suspect Aortic Dissection
  3. Known Traumatic Cardiopulmonary Resuscitation (CPR)
  4. Severe Hypertension despite Medication (>180/110)
  5. Major Intracranial Events
    1. Recent Head Trauma or intracranial neoplasm
    2. Known Arteriovenous Malformation or aneurysm
    3. Intracranial Hemorrhage on CT (CVA protocol)
    4. High suspicion SAH despite normal CT (CVA protocol)
    5. Cerebrovascular Accident (or TIA) in last 6 months
  6. Major surgery within last 14 days
    1. Highest risk surgeries for post-op bleeding: Brain or Spine Surgery
    2. Risk of major Hemorrhage within 1 week of surgery: 50%
    3. Risk of major Hemorrhage within 1-2 weeks of surgery: 20%
  7. Pregnancy
    1. Risk of bleeding 2.6%
    2. Consider in life-threatening massive Pulmonary Embolism if not near term
    3. Gartman (2013) Obstet Med 6:105-11 [PubMed]

VI. Contraindications: Relative

  1. Recent Trauma or major surgery in last 2 months
  2. Initial presenting BP > 180/110, but controlled now
  3. Peptic Ulcer Disease
  4. Remote history of Cerebrovascular Accident
  5. Known Bleeding Disorder
  6. Renal disease
  7. Prolonged Cardiopulmonary Resuscitation (CPR)
  8. Streptokinase in last 6 months

VII. Preparations

  1. Non-clot selective Thrombolytic agents
    1. Streptokinase
    2. Urokinase
    3. AniStreplase (anisoylated plasminogen Streptokinase)
    4. STAR (Recombinant Staphylokinase)
  2. Clot-Specific Thrombolytic agents
    1. T-PA (Alteplase, Activase)
      1. Recombinant tissue Plasminogen activator
    2. Recombinant Urokinase plasminogen activator
  3. Adjunctive Heparin (in acute Myocardial Infarction)
    1. Used in combination with Thrombolytic
    2. Contraindications to adjunctive Heparin
      1. Discharge from major surgery with prior 14 days
      2. History of Cerebrovascular Accident
      3. Chronic Atrial Fibrillation
      4. Chronic Mitral Stenosis
      5. Acute Gastrointestinal Hemorrhage
    3. Cases where adjunctive Heparin is most beneficial
      1. Acute anterior Myocardial Infarction
      2. Left ventricular thrombus by Echocardiogram

VIII. Adverse effects

  1. Bleeding
    1. Rescue agents for Thrombolytic-related life threatening bleeding (e.g. Intracranial Hemorrhage)
      1. See Emergent Reversal of Anticoagulation
      2. Not reduced by clot-specific agents
      3. Consider infusing Fibrinogen concentrate or Cryoprecipitate 10 pack
      4. Consider Fresh Frozen Plasma
      5. Consider Tranexamic Acid (TXA)
      6. Swaminathan and Weingart in Herbert (2020) EMRap 20(4):5-6
    2. Overall bleeding (Incidence: 20-25%)
      1. Occurs at catheter puncture sites most often
    3. Major bleeding (Incidence: 5-10%)
      1. Gastrointestinal Tract
      2. Retroperitoneum
      3. Intracranial Hemorrhage (1-2% of cases)
        1. Occurs more often with bolus than with infusion
  2. Acute Myocardial Infarction specific effects
    1. Reperfusion Chest Pain
    2. Reperfusion Arrhythmia
      1. Accelerated Idioventricular Rhythm
      2. Sinus Bradycardia
      3. Second or third degree AV Block
  3. Hypotension (Streptokinase)
  4. Nausea and Vomiting
  5. Allergic Reactions or Anaphylaxis (Streptokinase)

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Related Studies

Ontology: Fibrinolytic Agents (C0016018)

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
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