Algorithm for Fibrinolytic Therapy of Acute STEMI - Flowchart
Algorithm for Fibrinolytic Therapy of Acute STEMI - Flowchart
«Flowchart»

SELECTION CRITERIA


    Acute chest discomfort characteristic of myocardial infarction
    ECG criteria for ST-elevation MI (a, b, or c):

      ST elevation >0.1 mV (1 mm) in at least 2 leads of either:


      Inferior group: II, III, aVF
      Lateral group: I, aVL, V5, V6


      ST elevation >0.2 mV (1 mm) in at least 2 contiguous anterior leads (V1–V4)
      New LBBB

    Primary PCI not available, or delay to PCI would be >1 h longer than initiation of fibrinolysis

SELECTION CRITERIA


    Acute chest discomfort characteristic of myocardial infarction
    ECG criteria for ST-elevation MI (a, b, or c):

      ST elevation >0.1 mV (1 mm) in at least 2 leads of either:


      Inferior group: II, III, aVF
      Lateral group: I, aVL, V5, V6


      ST elevation >0.2 mV (1 mm) in at least 2 contiguous anterior leads (V1–V4)
      New LBBB

    Primary PCI not available, or delay to PCI would be >1 h longer than initiation of fibrinolysis

SELECTION CRITERIA

SELECTION CRITERIA

    Acute chest discomfort characteristic of myocardial infarction
    ECG criteria for ST-elevation MI (a, b, or c):

      ST elevation >0.1 mV (1 mm) in at least 2 leads of either:


      Inferior group: II, III, aVF
      Lateral group: I, aVL, V5, V6


      ST elevation >0.2 mV (1 mm) in at least 2 contiguous anterior leads (V1–V4)
      New LBBB

    Primary PCI not available, or delay to PCI would be >1 h longer than initiation of fibrinolysis

Acute chest discomfort characteristic of myocardial infarction
ECG criteria for ST-elevation MI (a, b, or c):

    ST elevation >0.1 mV (1 mm) in at least 2 leads of either:


    Inferior group: II, III, aVF
    Lateral group: I, aVL, V5, V6


    ST elevation >0.2 mV (1 mm) in at least 2 contiguous anterior leads (V1–V4)
    New LBBB

ST elevation >0.1 mV (1 mm) in at least 2 leads of either:


Inferior group: II, III, aVF
Lateral group: I, aVL, V5, V6


Inferior group: II, III, aVF
Lateral group: I, aVL, V5, V6 5 6
ST elevation >0.2 mV (1 mm) in at least 2 contiguous anterior leads (V1–V4) 1 4
New LBBB
Primary PCI not available, or delay to PCI would be >1 h longer than initiation of fibrinolysis

ASSESS FOR CONTRAINDICATIONS


Prior intracranial bleeding
Intracranial malignancy or vascular malformation
Ischemic stroke or head trauma in previous 3 months
Aortic dissection
Active bleeding (with exception of menses)
Internal bleeding in previous 4 weeks
Severe hypertension (systolic >180 or diastolic >110)
Prolonged (>10 min) CPR chest compressions
INR >2.0 on warfarin, or known bleeding diathesis
Pregnancy

ASSESS FOR CONTRAINDICATIONS


Prior intracranial bleeding
Intracranial malignancy or vascular malformation
Ischemic stroke or head trauma in previous 3 months
Aortic dissection
Active bleeding (with exception of menses)
Internal bleeding in previous 4 weeks
Severe hypertension (systolic >180 or diastolic >110)
Prolonged (>10 min) CPR chest compressions
INR >2.0 on warfarin, or known bleeding diathesis
Pregnancy

ASSESS FOR CONTRAINDICATIONS

ASSESS FOR CONTRAINDICATIONS


Prior intracranial bleeding
Intracranial malignancy or vascular malformation
Ischemic stroke or head trauma in previous 3 months
Aortic dissection
Active bleeding (with exception of menses)
Internal bleeding in previous 4 weeks
Severe hypertension (systolic >180 or diastolic >110)
Prolonged (>10 min) CPR chest compressions
INR >2.0 on warfarin, or known bleeding diathesis
Pregnancy


Prior intracranial bleeding
Intracranial malignancy or vascular malformation
Ischemic stroke or head trauma in previous 3 months
Aortic dissection
Active bleeding (with exception of menses)
Internal bleeding in previous 4 weeks
Severe hypertension (systolic >180 or diastolic >110)
Prolonged (>10 min) CPR chest compressions
INR >2.0 on warfarin, or known bleeding diathesis
Pregnancy

FIBRINOLYTIC DRUG : INTRAVENOUS DOSAGE
Streptokinase : 1.5 million U over 60 min
Alteplase* : 15-mg bolus, then 0.75 mg/kg (up to 50 mg) over 30 min, then 0.5 mg/kg (up to 35 mg) over 60 min
Reteplase* : 10 U over 2 min; repeat same dose 30 min later
Tenecteplase* Single bolus of 0.53 mg/kg over 10 sec.


<60 kg: 30 mg
60–69 kg: 35 mg
70–79 kg: 40 mg
80–89 kg: 45 mg
>90 kg: 50 mg

FIBRINOLYTIC DRUG : INTRAVENOUS DOSAGE
Streptokinase : 1.5 million U over 60 min
Alteplase* : 15-mg bolus, then 0.75 mg/kg (up to 50 mg) over 30 min, then 0.5 mg/kg (up to 35 mg) over 60 min
Reteplase* : 10 U over 2 min; repeat same dose 30 min later
Tenecteplase* Single bolus of 0.53 mg/kg over 10 sec.


<60 kg: 30 mg
60–69 kg: 35 mg
70–79 kg: 40 mg
80–89 kg: 45 mg
>90 kg: 50 mg

FIBRINOLYTIC DRUG : INTRAVENOUS DOSAGE
Streptokinase : 1.5 million U over 60 min
Alteplase* : 15-mg bolus, then 0.75 mg/kg (up to 50 mg) over 30 min, then 0.5 mg/kg (up to 35 mg) over 60 min
Reteplase* : 10 U over 2 min; repeat same dose 30 min later
Tenecteplase* Single bolus of 0.53 mg/kg over 10 sec.


<60 kg: 30 mg
60–69 kg: 35 mg
70–79 kg: 40 mg
80–89 kg: 45 mg
>90 kg: 50 mg


FIBRINOLYTIC DRUG INTRAVENOUS DOSAGE

* *
* *
* *


<60 kg: 30 mg
60–69 kg: 35 mg
70–79 kg: 40 mg
80–89 kg: 45 mg
>90 kg: 50 mg


<60 kg: 30 mg
60–69 kg: 35 mg
70–79 kg: 40 mg
80–89 kg: 45 mg
>90 kg: 50 mg

SUBSEQUENT CORONARY ANGIOGRAPHY RESERVED FOR


Failure of reperfusion (persistent chest pain or ST elevation after 90 min)
Spontaneous recurrent ischemia during hospitalization
High risk features: e.g., extensive ST elevation, heart failure, hypotension

SUBSEQUENT CORONARY ANGIOGRAPHY RESERVED FOR


Failure of reperfusion (persistent chest pain or ST elevation after 90 min)
Spontaneous recurrent ischemia during hospitalization
High risk features: e.g., extensive ST elevation, heart failure, hypotension

SUBSEQUENT CORONARY ANGIOGRAPHY RESERVED FOR

SUBSEQUENT CORONARY ANGIOGRAPHY RESERVED FOR


Failure of reperfusion (persistent chest pain or ST elevation after 90 min)
Spontaneous recurrent ischemia during hospitalization
High risk features: e.g., extensive ST elevation, heart failure, hypotension


Failure of reperfusion (persistent chest pain or ST elevation after 90 min)
Spontaneous recurrent ischemia during hospitalization
High risk features: e.g., extensive ST elevation, heart failure, hypotension

* If alteplase, reteplase, or tenecteplase used, also administer IV heparin 60-U/kg bolus (maximum 4000 U) followed by 12 (U/kg)/h (maximum 1000 U/h), then adjusted to maintain aPTT at 1.5–2 × control (~50–70 s) for 48 h

* If alteplase, reteplase, or tenecteplase used, also administer IV heparin 60-U/kg bolus (maximum 4000 U) followed by 12 (U/kg)/h (maximum 1000 U/h), then adjusted to maintain aPTT at 1.5–2 × control (~50–70 s) for 48 h

* If alteplase, reteplase, or tenecteplase used, also administer IV heparin 60-U/kg bolus (maximum 4000 U) followed by 12 (U/kg)/h (maximum 1000 U/h), then adjusted to maintain aPTT at 1.5–2 × control (~50–70 s) for 48 h

*

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