DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
- There is no upper age limit for this treatment
- Cardiogenic shock and ventricular arrhythmias are not contraindications to thrombolysis
INDICATIONS
- Default treatment for STEMI in the UK is primary PCI (pPCI)
- Role of thrombolysis is limited to cases where there is a delay in the system, that means that pPCI is unlikely to be achieved within 120 min, then a thrombolytic strategy should be deployed
- Aim should be to deliver thrombolysis within 10 min of taking decision that the patient will not achieve pPCI within the 120 min window
- Once thrombolysis delivered, arrange transfer to a pPCI centre
- Typical STEMI criteria apply
- presentation within 12 hr of onset of symptoms
- typical cardiac chest pain persisting for >30 min
- >1 mm ST segment elevation in 2 or more precordial leads or 2 or more bipolar leads or >1 mm ST segment depression in leads V1–V3 (suggesting acute posterior infarction) or LBBB with any of the following in leads V1–V3:
- >1 mm ST segment depression
- >1 mm ST segment elevation where QRS complex positive
- >5 mm ST segment elevation where QRS complex negative
CONTRAINDICATIONS
- Absolute:
- active bleeding
- Relative:
- major trauma/major surgery within previous 4 weeks
- stroke/TIA within previous 3 months
- confirmed subarachnoid haemorrhage at any time
- traumatic cardiac massage or intracardiac injection
- known bleeding disorder
- active dyspepsia or history of GI haemorrhage
- sustained systolic BP ≥180 mmHg
- proliferative retinopathy
- recent head injury
- pericarditis
- INR >2.0
STANDARD AGENT IS TENECTEPLASE (METALYSE®)
- Administer tenecteplase based on body weight, with a maximum dose of 10,000 units (tenecteplase 50 mg) according to table below. However, any bolus, fibrin specific thrombolytic is acceptable (such as alteplase – check BNF for treatment regimen). For patients aged >75 yr use half dose of bolus thrombolytic
Choose a body weight:
Tenectoplase: 6000 units; 30mg with corresponding volume of reconstituted solution 6 mL
Tenectoplase: 7000 units; 35mg with corresponding volume of reconstituted solution 7 mL
Tenectoplase: 8000 units; 40mg with corresponding volume of reconstituted solution 8 mL
Tenectoplase: 9000 units; 45mg with corresponding volume of reconstituted solution 9 mL
Tenectoplase: 10000 units; 50mg with corresponding volume of reconstituted solution 10 mL
- Administer by giving unfractionated heparin 5000 units by IV bolus, followed by tenecteplase administered as a single IV bolus over approximately 10 seconds, then give unfractionated heparin 1000 units/hr via infusion pump for 48 hr, adjusting dose to maintain APTT ratio 1.5-2.0
COMPLICATIONS
- Hypotension - if occurs de novo, review for cardiogenic shock, mitral regurgitation or tamponade. If thrombolysis being administered, stop IV infusion and recommence at a slower rate after BP has recovered
- Bradycardia - usually responds to atropine 300 microgram IV
- Ventricular tachycardia or idioventricular rhythm - usually self-limiting and requires no therapy. If sustained - see Cardiac arrhythmias guideline
- Avoid arterial puncture, central venous cannulation and IM injections in patients undergoing thrombolytic therapy, unless essential to patient care