Fibrinolytic therapy contraindication

Contraindications to Fibrinolytic Therapy in Patients With ST-Elevation Myocardial Infarction... 

TABLE 5-3. Indications and Contraindications to Fibrinolytic Therapy per ACC/AHA Guidelines for Management of Patients with ST-Segment Elevation Myocardial Infarction3... 

Absolute contraindications to fibrinolytic therapy include (1) active internal bleeding (2) previous ICH at anytime (3) ischemic stroke within 3 months (4) known intracranial neoplasm (5) known structural vascular lesion (6) suspected aortic dissection and (7) significant closed head or facial trauma within 3 months. Primary PCI is preferred in these situations. 

The basic concept of prehospital care and patient transfer is carrying the patient to a facility capable of rapid revascularization, if fibrinolysis therapy is contraindicated. If the patient cannot be transferred to the facility capable of prompt intervention, fibrinolytic therapy is strongly recommended to start within 90 minutes of first medical contact. After such treatment, medical therapy will become important in managing the patient. 

The indication for fibrinolytic therapy has to be weighed against the absolute or relative contraindications, The earlier the patient is presented and the larger the area at risk recorded in the presenting electrocardiogram, the more beneficial fibrinolytic therapy is, and more contraindications are relative, The later the patient is presented and the smaller the area at risk, the less fibrinolytic therapy is beneficial and the more contraindications are stringent,... 

Adverse effects. Bleeding is the most important complication and usually occurs at a vascular lesion, e.g. the site of injection, for fibrinolytic therapy does not distinguish between an imdesired thrombus and a useful haemostatic plug. If the contraindications are followed, the incidence of bleeding severe enough to require transfusion is < 1%. Nausea and vomiting may occur. 

Data regarding the acute benefit of /3-blockers in MI in the reperfusion era is derived mainly from the Thrombolysis in Myocardial Infarction (TIMI) II trial. In this trial, patients with ST-segment-elevation ACS were randomized to either IV metoprolol to be given as soon as possible following fibrinolytic administration followed by oral metoprolol or oral metoprolol deferred until day 6. Early administration of metoprolol was associated with a significant decrease in recurrent ischemia and early reinfarction. Patients receiving fibrinolytic therapy within 2 hours of symptom onset demonstrated the greatest benefit from early metoprolol administration. Based on the results of these trials, early administration of /8-blockers (to patients without contraindications) within the first 24 hours of hospital admission is a standard of quality patient care (see Table 16-3). 

Initial fibrinolytic therapy (in patients who have no absolute contraindication to thrombolysis) should be combined with administration of conjunctive pharmacological agents to enhance lysis and minimize the risk of Weeding. 

Numerous observational studies have confirmed the treatment benefit seen in the above RCTs of primary PCI as a reperfusion strategy in the elderly. In the previously mentioned analysis of the CCP, Berger et al. found primary PCI compared with no reperfusion was associated with significant reductions in both 30-day and 1-year mortality among patients without absolute contraindications for fibrinolytic therapy (13). Among the ideal patient subgroup, primary PCI yielded reductions in adjusted mortahty rates at 30 days and at 1 year compared with no therapy (OR 0.78,95% Cl 0.58-1.05 and OR 0.63,95% Cl 0.49-0.84). However, since this analysis used no reperfusion therapy as the comparison group, primary PCI and fibrinolytic therapy were not directly compared. 

In a separate analysis of the CCP, Berger et al. compared primary PCI directly to fibrinolytic therapy (36). The outcomes of 18,645 patients who received fibrinolytic Iherapy were compared with 2038 patients who received primary PCI. This cohort was composed of patients >65 years of age, not in cardiogenic shock, within 12 hours from symptom onset and with no contraindications to fibrinolytic therapy. Among the entire cohort, primary PCI resulted in lower crude and adjusted rates of 30-day and 1-year mortality. The benefit of PCI persisted even in those >75 years of age. 

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