{"id":111,"date":"2008-11-22T17:29:01","date_gmt":"2008-11-22T17:29:01","guid":{"rendered":"http:\/\/cardiophile.info\/?p=111"},"modified":"2008-11-22T17:29:01","modified_gmt":"2008-11-22T17:29:01","slug":"thrombolysis-in-myocardial-infarction","status":"publish","type":"post","link":"https:\/\/johnsonfrancis.org\/professional\/thrombolysis-in-myocardial-infarction\/","title":{"rendered":"Thrombolysis in myocardial infarction"},"content":{"rendered":"<p><iframe loading=\"lazy\" width=\"560\" height=\"315\" src=\"https:\/\/www.youtube.com\/embed\/mx9BWYwQbtA\" title=\"YouTube video player\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture\" allowfullscreen=\"\"><\/iframe><\/p>\n<h2><span style=\"color: #008000;\">Thrombolysis in myocardial infarction<\/span><\/h2>\n<p><strong>Thrombolysis in myocardial infarction<\/strong><\/p>\n<p><em><strong>Chronology of development of thrombolytic agents<\/strong><\/em><\/p>\n<p><em>First Generation:<\/em><\/p>\n<p>Streptokinase<br \/>\nAnisoylated plasminogen streptokinase activator complex (APSAC)<\/p>\n<p><em>Second Generation:<\/em><\/p>\n<p>Alteplase &nbsp;&#8211; Recombinant tissue plasminogen activator<\/p>\n<p><em>Third Generation:<\/em><\/p>\n<p>Reteplase<br \/>\nLanoteplase<br \/>\nTenecteplase &#8211; TNK tPA<\/p>\n<p><em><strong>Characteristics of an ideal thrombolytic agent<\/strong><\/em><\/p>\n<p>1. Long half-life<br \/>\n2. Single-bolus administration<br \/>\n3. High fibrin specificity\/decreased bleeding and intracranial hemorrhage<br \/>\n4. Resistant to PAI-1<br \/>\n5. Rapid action<br \/>\n6. Reduction in 30 day mortality<br \/>\n7. No effect on blood pressure<br \/>\n8. No antigenicity<br \/>\n9. No re-occlusion<br \/>\n10. Compatible with other intravenous agents<br \/>\n<em><em>An ideal thrombolytic agent is yet to be developed!<\/em><\/em><\/p>\n<p><em><strong>Streptokinase<\/strong><\/em><\/p>\n<p>Streptokinase was the first fibrinolytic to be extensively used in acute myocardial infarction. It is a bacterial protein from group C-\u00df streptococcus. Streptokinase complexes with plasminogen and converts plasminogen to plasmin. Two placebo-controlled trials, GISSI (1986; 11,712 patients) and ISIS-2 (1988; 17,187 patients) demonstrated the effectiveness of thrombolysis in acute myocardial infarction with streptokinase and documented the benefit in terms of mortality reduction.<\/p>\n<p><em>Disadvantages\/ limitations of streptokinase<\/em><\/p>\n<p>Streptokinase requires 1 hour for administration and it is not a direct activator of plasmin. Neither is it fibrin specific. Hence there is a chance for increased systemic bleeding. Streptokinase is immunogenic and allergic reactions can occur rarely. Its effectiveness is decreased if given within 5 days to 12 months of prior use.<\/p>\n<p><em><strong>Alteplase (recombinant t-PA)<\/strong><\/em><\/p>\n<p>Alteplase (recombinant t-PA) is cloned from human t-PA. Unlike streptokinase, it is non-immunogenic. It has a short half life of 4-8 minutes. Hence it has to be administered over a period of 90 minutes. The 90-minute schedule is an accelerated infusion compared to the longer period of infusion which was used earlier. Alteplase has been shown to reduce mortality in GUSTO-I trial.<\/p>\n<p><em>Disadvantages \/ limitations of alteplase<\/em><\/p>\n<p>Since it has to be given as an intravenous infusion, pre-hospital use impractical or difficult. Even the \u201caccelerated\u201d schedule takes 90 minutes to administer. Alteplase is inhibited by PAI-1 (Plasminogen activator inhibitor).<\/p>\n<p><em><strong>Reteplase<\/strong><\/em><\/p>\n<p>Reteplase is the first genetically modified tPA. It is non-immunogenic like tPa. Reteplase has a longer half-life permitting usage as double bolus 30 minutes apart. Its efficacy in comparable to t-PA and has been documented by GUSTO-III trial.<\/p>\n<p><em>Disadvantages\/ limitations of reteplase<\/em><\/p>\n<p>30 minutes are required for administration. It is less fibrin specific than alteplase. Reteplase is not resistant to PAI-I.<\/p>\n<p><em><strong>Lanoteplase<\/strong><\/em><\/p>\n<p>Lanoteplase is a mutant of wild-type t-PA. It is fibrin-selective and has a half-life of 37 minutes, permitting usage as a single bolus. But Lanoteplase causes an increased incidence of intracranial hemorrhage and hence its usage has been discontinued.<\/p>\n<p><em><strong>Tenecteplase<\/strong><\/em><\/p>\n<p>Tenecteplase is a genetically engineered variant of alteplase. It can be administered as single bolus and it is resistant to inactivation by PAI-1. Tenecteplase is fibrin specific. It is useful for pre-hospital thrombolysis.<\/p>\n<p><em><strong>T<\/strong><strong>hrombolysis vs primary angioplasty in acute ST elevation myocardial infarction<\/strong><\/em><\/p>\n<p>Fibrinolysis is considered when:<\/p>\n<p><em>Early presentation<\/em> (\u22643 hours AND delay to invasive strategy)<\/p>\n<p><em>Invasive strategy is not an option<\/em> as in<br \/>\n&#8211; Cath lab occupied \/ not available<br \/>\n&#8211; Vascular access difficulties<br \/>\n&#8211; Lack of access to a skilled PCI lab<\/p>\n<p><em>Delay to invasive strategy<\/em><br \/>\n&#8211; Prolonged transport<br \/>\n&#8211; (Door-to-Balloon) \u2013 (Door-to-Needle) time &gt; 1 hour<br \/>\n&#8211; Door-to-balloon time is &gt; 90 min<\/p>\n<p><em><strong>Contraindications for thrombolysis: Absolute<\/strong><\/em><\/p>\n<p>Any prior intracranial hemorrhage<br \/>\nKnown structural cerebral vascular lesion<br \/>\nKnown malignant intracranial neoplasm<br \/>\nIschemic stroke within 3 months EXCEPT acute ischemic stroke within 4.5 hours<br \/>\nSuspected aortic dissection<br \/>\nActive bleeding or bleeding diathesis<br \/>\nSignificant closed-head or facial trauma within 3 months<\/p>\n<p><em><strong>Contraindications for thrombolysis: Relative<\/strong><\/em><\/p>\n<p>Severe uncontrolled hypertension on presentation (&gt; 180 \/ 110 mmHg)<br \/>\nH\/o prior ischemic stroke &gt; 3 months, dementia, or known intracranial pathology not covered in contraindications<br \/>\nTraumatic or prolonged (&gt; 10 minutes) CPR or major surgery (&lt; 3 weeks)<br \/>\nRecent (&lt; 2 to 4 weeks) internal bleeding Noncompressible vascular punctures For streptokinase: prior exposure (&gt;5 days ago) or prior allergic reaction to these agents<br \/>\nPregnancy<br \/>\nActive peptic ulcer<br \/>\nCurrent use of anticoagulants: the higher the INR, the higher the risk of bleeding<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Thrombolysis in myocardial infarction can be considered in early presentations if percutaneous coronary intervention is not available or delayed.<\/p>\n","protected":false},"author":1,"featured_media":38569,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","footnotes":""},"categories":[9],"tags":[],"class_list":["post-111","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-general"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.9 - 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