Fibrinolytic agents present the only available pharmacotherapy able to dissolve a thrombus and open occluded vessels. Despite the worldwide experience with fibrinolytic therapy, there are limitations that must be considered.
As with all other management strategies for Acute Coronary Syndrome (ACS), contraindications for fibrinolytics in patients diagnosed with an ST-elevated myocardial infarction (STEMI) must be considered.
Discuss in detail the absolute and relative contraindications for fibrinolytic therapy in STEMI.
Full Answer Section
- Severe uncontrolled hypertension (systolic blood pressure >180 mmHg or diastolic blood pressure >110 mmHg)
- Active peptic ulcer disease
- Aortic dissection
- Pericarditis
Relative Contraindications to Fibrinolytic Therapy in STEMI
Relative contraindications to fibrinolytic therapy in STEMI are conditions in which the risk of bleeding is increased, but the potential benefit of reperfusion therapy may still outweigh the risks. These contraindications include:
- Recent ischemic stroke (within the past 3-6 months)
- Pregnancy
- Severe traumatic brain injury or facial trauma (within the past 3-6 months)
- Recent major surgery (within the past 3-6 weeks)
- Severe uncontrolled diabetes
- Severe renal failure
- Severe hepatic failure
- Coagulopathy or use of anticoagulant medications
- Age >75 years
Considerations for Fibrinolytic Therapy in STEMI
The decision of whether or not to use fibrinolytic therapy in a patient with STEMI must be made on a case-by-case basis, weighing the risks and benefits of therapy. In general, fibrinolytic therapy is most beneficial for patients who are at high risk of death or severe disability from their myocardial infarction. These patients include patients with:
- Large anterior infarctions
- Cardiogenic shock
- Left ventricular dysfunction
- Diabetes
- Advanced age
Fibrinolytic therapy is also more beneficial for patients who are treated early. The sooner fibrinolytic therapy is administered after the onset of symptoms, the more likely it is to be successful.
Risk Factors for Bleeding with Fibrinolytic Therapy
The following factors increase the risk of bleeding with fibrinolytic therapy:
- Older age
- Female sex
- Low body weight
- Severe hypertension
- Renal failure
- Hepatic failure
- Coagulopathy
- Use of anticoagulant medications
- Active peptic ulcer disease
- Recent intracranial hemorrhage
- Recent ischemic stroke
- Recent major surgery
- Traumatic brain injury or facial trauma
- Pregnancy
Management of Bleeding with Fibrinolytic Therapy
If a patient experiences bleeding while on fibrinolytic therapy, the following steps should be taken:
- Discontinue the fibrinolytic agent immediately.
- Replace any lost blood and fluids.
- Correct any underlying coagulopathy.
- Monitor the patient closely for further signs of bleeding.
In severe cases, it may be necessary to administer fresh frozen plasma or cryoprecipitate to reverse the effects of the fibrinolytic agent.
Conclusion
Fibrinolytic therapy is a valuable treatment option for patients with STEMI, but it is important to be aware of the contraindications and risks of therapy. The decision of whether or not to use fibrinolytic therapy in a patient with STEMI must be made on a case-by-case basis, weighing the risks and benefits of therapy.