Therapies thrombolytic

Several clinical trials have been conducted with streptokinase adrninistered either intravenously or by direct infusion into a catheterized coronary artery. The results from 33 randomized trials conducted between 1959 and 1984 have been examined (75), and show a significant decrease in mortaUty rate (15.4%) in enzyme-treated patients vs matched controls (19.2%). These results correlate well with an ItaUan study encompassing 11,806 patients (76), in which the overall reduction in mortaUty was 19% in the streptokinase-treated group, ie, 1.5 million units adrninistered intravenously, compared with placebo-treated controls. The trial also shows that a delay in the initiation of treatment over six hours after the onset of symptoms nullifies any benefit from this type of thrombolytic therapy. Conversely, patients treated within one hour from the onset of symptoms had a remarkable decrease in mortaUty (47%). The benefits of streptokinase therapy, especially in the latter group of patients, was stiU evident in a one-year foUow-up (77). In addition to reducing mortahty rate, there was an improvement in left ventricular function and a reduction in the size of infarction. Thus early treatment with streptokinase is essential. 

One drawback of thrombolytic therapy is a high incidence of reocclusion. In a report using a canine model, inclusion of heparin [9005-49-6] (anticoagulant therapy) in the treatment prevented this side effect (158). The combination of aspirin [50-78-2] (antiplatelet therapy) and streptokinase (thrombolytic therapy) has also shown significant therapeutic advantages (78). Although additional work is needed to estabUsh the thrombolytic advantage of various combinations, preliminary results in this area indicate promise in terms of increased efficacy and reduced side effects. 

A patient enters the emergency department with an acute MI. Thrombolytic therapy is begun with streptokinase Discuss ongoing assessments that are important for the nurse to perform. 

Krumholz HM, Pasternak RC, Weinstein MC, et al. Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction. N Engl J Med 1992 327 7-13. 

Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000 355 1670-1674. 

Wildermuth S, Knauth M, Brandt T, Winter R, Sartor K, Hacke W. Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke. Stroke 1998 29 935-938 [see comment]. 

O Connor RE, McGraw P, Edelsohn L. Thrombolytic therapy for acute ischemic stroke why the majority of patients remain ineligible for treatment. Ann Emerg Med 1999 33 9-14. 

Neumann-Haefelin C, Brinker G, Uhlenkuken U, Pillekamp F, Hossmann KA, Hocehn M. Prediction of hemorrhagic transformation after thrombolytic therapy of clot embolism an MRI investigation in rat brain. Stroke 2002 33 1392-1398. 

Warach S, Latour LL. Evidence of reperfusion injury, exacerbated by thrombolytic therapy, in human focal brain ischemia using a novel imaging marker of early blood-brain barrier disruption. Stroke 2004 35 2659-2661. 

Stroke is the leading cause of major long-term disability in adults and the third leading cause of death in the United States. On average, a new stroke occurs every 45 seconds. Thrombolytic therapy with intravenous recombinant tissue-plasminogen activator (IV rt-PA) is the most effective treatment for acute ischemic stroke. In this chapter, we review the rationale for thrombolysis in acute ischemic stroke, clinical evidence supporting the use of thrombolytics, and the application of thrombolysis in practice. 

Marder VJ, Sherry S. Thrombolytic therapy Current status. N Engl J Med. 1988 318 1512-1520. 

Clark WM, Albers GW, Madden KR Hamilton S. The rtPA (alteplase) 0- to 6-hour acute stroke trial, part a (a0276g) results of a double-bhnd, placebo-controlled, multicenter study. Thrombolytic Therapy in Acute Ischemic Stroke Study Investigators. Stroke. 2000 31 811-816. 

Albers GW, Amarenco R Easton JD, Sacco RL, Teal R. Antithrombotic and thrombol3ftic therapy for ischemic stroke The seventh ACCR Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 126 483S-512S. 

Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial-Europe study group. N Engl J Med. 1996 335 145-150. 

Practice advisory Thrombolytic therapy for acute ischemic stroke-summary statement. Report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 1996 47 835-839. 

Heuschmann PU, Berger K, Misselwitz B, Hermanek P, Leffmann C, Adelmann M, Buecker-Nott HI, Rother J, Neundoerfer B, Kolominsky-Rabas PL. Frequency of thrombolytic therapy in patients with acute ischemic stroke and the risk of in-hospital mortality The German Stroke Registers Study Group. Stroke. 2003 34 1106-1113. 

Schriger DL, Kalafut M, Starkman S, Krueger M, Saver JL. Cranial computed tomography interpretation in acute stroke physician accuracy in determining eligibility for thrombolytic therapy. JAMA. 1998 279 1293-1297. 

INR > 1.7 (PT > 15 if no INR available) with or without chronic oral anticoagulant use Seizure at onset of stroke (This relative contraindication is intended to prevent treatment of patients with a deficit due to postictal Todd s paralysis or with seizure due to some other CNS lesion that precludes thrombolytic therapy. If rapid diagnosis of vascular occlusion can be made, treatment may be given.)... 

Saver JL. Number needed to treat estimates incorporating effects over the entire range of clinical outcomes novel derivation method and application to thrombolytic therapy for acute stroke. Arch Neurol 2004 61 1066-1070. 

Zaidat OO, Suarez Jl, Santillan C, Sunshine JL, Tarr RW, Paras VH, Selman WR, Landis DM. Response to intra-arterial and combined intravenous and intra-arterial thrombolytic therapy in patients with distal internal carotid artery occlusion. Stroke 2002 33 1821-1826. 

Schellinger PD, Fiebach JB, Hacke W. Imaging-based decision making in thrombolytic therapy for ischemic stroke present status. Stroke 2003 34 575-583. 

Leigh R, Zaidat OO, Suri ME, L3mch G, Sundararajan S, Sunshine JL, Tarr R, Selman W, Landis DM, Suarez JI. Predictors of hyperacute chnical worsening in ischemic stroke patients receiving thrombolytic therapy. Stroke 2004 35 1903-1907. 

Antithrombotic and Thrombolytic Therapy for Ischemic Stroke The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy 2004 ... 

Low-dose heparin should be restricted for 24 hours after administration of thrombolytic therapy. Low-dose heparin may be used safely in combination with aspirin. 

If thrombolytic therapy is planned, no aspirin should be given. 

Aspirin is not allowed for 24 hours after thrombolytic therapy. 

Smith AG, Cornblath WT, Deveikis JP. Local thrombolytic therapy in deep cerebral venous thrombosis. Neurology 1997 48 1613-1619. 

More recently, thrombolytic therapy was reported in 106 patients as part of the TEMPiS system in Bavaria, Germany. The network consists of two comprehensive and 12 regional centers connected by around-the-clock telemedicine support for stroke care. In the first year following intervention, the number of patients treated with rt-PA increased to 86 patients (2% of all patients admitted with stroke), compared to 10 patients treated in the year preceding intervention. The rate of symptomatic hemorrhage was 8.5%, similar to the NINDS trial. " ... 

Von Rummer R, Allen KL, Holle R, Bozzao L, Bastianello S, Manelfe C, Bluhmki E, Ringleb P, Meier DH, Hacke W. Acute stroke usefulness of early CT findings before thrombolytic therapy. Radiology 1997 205 327-333. 

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