Inclusion:
- Ischemic symptoms < 12 hours (at/after ) [Class I]
- Evidence of ongoing ischemia 12-24h after symptom onset and a large area of myocardium at risk or ongoing hemodynamic instability [Class 2A]
- > 120 min delay until primary PCI (at/after ) [Class I]
Absolute Contraindications:
- Any prior intracranial hemorrhage (ICH)
- Known structural cerebral vascular lesion (ex: AVM)
- Known malignant intracranial neoplasm (primary or metastatic)
- Ischemic stroke within 3 months (except acute ischemic stroke w/in 4.5h)
- Suspected aortic dissection
- Active bleeding or bleeding diathesis
- Significant closed-head or facial trauma within 3 months
- Intracranial or intraspinal surgery within 2 months
- Severe uncontrolled hypertension (unresponsive to emergency therapy)
- For streptokinase, prior treatment within the prior 6 months
Relative Contraindications:
- History of chronic, severe, poorly controlled hypertension
- BP > 180/110 on presentation
- History of prior ischemic stroke > 3 months ago
- Dementia
- Known intracranial pathology not excluded by absolute contraindications
- Traumatic or prolonged (> 10min) CPR
- Major surgery within 3 weeks
- Internal bleeding within 2-4 weeks
- Noncompressible vascular punctures
- Pregnancy
- Active peptic ulcer
- Oral anticoagulant therapy
Dosing of tPA (Alteplase, Activase®)
Additional medication dosing:
- Aspirin 162-325mg PO
- Clopidogrel (Plavix®) 300mg PO x1
- Nitroglycerin:
- 0.4mg SL x3 q5min prn chest pain
- 0.5-2 inch topically to chest for chest pain
Class I evidence for aspirin, plavix, and an anticoagulant after receiving fibrinolytic therapy.
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2013; 61(4): e78-e140.