VENTURA COUNTY MEDICAL CENTER

CLINICAL PRACTICE GUIDELINES / PROTOCOLS

MI THROMBOLYSIS, MANAGEMENT OF
The contents of this clinical practice guideline are to be used as a guide. Healthcare professionals should use
sound clinical judgment and individualize patient care. This CPG is not meant to be a replacement for
training, experience, CME or studying the latest literature and drug information.

I. CANDIDATE FOR THROMBOLYSIS IN ACUTE MI.

A. DEFINITE:

1. Patients who present with chest pain consistent with a diagnosis of acute ST segment
elevation MI and at least 0.1 mV of ST segment elevation in at least 2 contiguous EKG leads
with time to treatment 12 hours or less, age less than 75 years.
2. Patients who present with chest pain consistent with a diagnosis of acute MI and a Bundle
Branch Block (obscuring ST- segment analysis) with time to treatment 12 hours or less, age
less than 75 years.

B. PROBABLE:
1. Patients 75 years or older who present with chest pain consistent with a diagnosis of acute ST
segment elevation MI and at least 0.1 mV of ST elevation in at least two contiguous EKG
leads with time to treatment 12 hours or less.

II. CONTRAINDICATIONS:

A. ABSOLUTE
1. Previous hemorrhagic stroke at any time
2. Ischemic or embolic stroke within 1 year
3. Known intracranial neoplasm
4. Active internal bleeding (does not include menses)
5. Suspected aortic dissection

B. RELATIVE
1. Uncontrolled HTN>180/110 mmHg
1. HX of prior CVA or known intracerebral pathology not covered in absolute
contraindications.
2. Use of anticoagulants in therapeutic doses (INR> 2)
3. Coagulopathy
4. Recent trauma (within 2-4 weeks), including head trauma, major surgery (<3 weeks) or
prolonged CPR>10 minutes.
5. Non compressible vascular puncture.
6. Recent (within 2-4 weeks) internal bleeding
7. Pregnancy
8. Active peptic ulcer
9. Chronic severe hypertension

III. PROCEDURE:

A. The Cardiologist or the Staff ER Attending in consultation with the cardiologist or intensivist
will initiate thrombolytic therapy in the ER. The cardiologist will be notified as soon as possible.
The Attending Staff Physician will be present during the procedure until the patient's condition is
stable.

B. GENERAL CARE:

1. Start two IVs, one IV for drug access, one IV with large bore (16-18 gauge) Jelco in large
stable vein of forearm opposite first IV site along with 3-way stopcock and heparin lock
to be used for drawing lab work.
2. 02 via nasal cannula at 2 liters/min-to keep 02 sat>90%
3. Check vital signs-notify MD immediately if BP>160/90 or <100 systolic
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MI Thrombolysis, Mgmt of

4. Continuous EKG monitoring looking for arrhythmias or ST changes

5. NPO except for meds and sips of water
6. Have infusion pump with guardrails available.
7. Monitor BP with automatic BP device-

C. LAB

1. STAT LAB
A. EKG, CXR
B. CBC, lytes, creatinine, glucose, serial cardiac enzymes, INR, aPTT, and stool
guaiac
2. REPEAT LAB
A. EKG
EKG repeated after first dose of RETAPLASE and after second dose. Repeat
EKG at 4 hours, 12 hours post admission and daily for 3 days.
B. CXR-on admission
C. CARDIAC ENZYMES
Repeat at 4,8,12 hours after admission, then twice daily for 48 hours.
D. aPTT
See THROMBOLYTIC AGENTS

D. MEDS:

1. ASPIRIN - 325 mg stat -chew and swallow, then ASA 81 mg daily.

If NPO, ASA 325 mg per rectum

2. THROMBOLYTIC AGENT- Door-to-needle time < 30 minutes

Reteplase (Retavase )
HEPARIN 60 units/kg (max5000units) is given followed by a constant infusion of
heparin @ 12 micrograms per hour (max 1000 units/hr) for 24 hours.

RETAPLASE-After heparin bolus, 10 units Reteplase is given over 2 minutes via a

dedicated IV line in which no other medication is being infused.

Repeat 10 units of Reteplase 30 minutes after initiation of the first bolus. If Reteplase is
given through the heparin line, flush with normal saline before starting the RETAPLASE
bolus.

Check aPTT at 6 hours (target 1.5 to 2 X control or 50-75 seconds,

(See attached arterial heparin protocol.)

3. BETA BLOCKER: Consult Attending prior to starting. Start within 12 hours.

MYOCARDIAL SALVAGE, RECURRENT ISCHEMIA, RAPID A FIB) – Metoprolol
(Lopressor ®) 5 mg IV q 5 minutes X 3 doses, followed in 15 minutes by 50 mg orally
every 6 hours for 48 hours, then 100 mg orally twice daily.

CONTRAINDICATIONS TO BETA BLOCKER:

Heart rate < 60 bpm
SBP < 100 mmHg
Acute CHF
PR interval > 0.24 seconds, 2' or 3' AV BLOCK
Asthma
Concurrent use of Verapamil, diltiazem
Severe peripheral vascular disease

4. ATORVASTATIN (Lipitor): 80 mg is given orally stat, then 80 mg daily.

5. CLOPIDOGREL (Plavix): 300 mg is given orally stat, the 75 mg daily

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MI Thrombolysis, Mgmt of

6. ACE INHIBITIOR:
start low dosage (CAPTROPRIL 6.25 mg once or twice daily)
INDICATIONS: within 24 hours of acute MI---IF: BP after thrombolysis and
beta blocker still elevated >160 mmHg otherwise start on day 2.

CONTRAINDICATIONS:
SBP < 100 mmHg
Renal failure- (creatinine > 2.5 mg/ml)
HX bilateral renal artery stenosis
Allergy to ACEI

7. NITROGLYCERIN: IV FOR 24-48 hrs

INDICATIONS:
Acute MI & Recurrent Ischemia
Acute MI & persistence of CHF
Acute MI & HTN
IV-10-20 micrograms/minute increase by 5 micrograms/minute until clinical
response or SBP< 110 mm Hg
SL-NTG 0.4 mg SL as needed for anginal pain

8. LIDOCAINE:
If significant ventricular arrhythmias are present: 1-1.5mg/Kg via IV bolus,
may repeat 0.5 mg/Kg dose every 10 minutes up to total dose of 3mg/Kg,
then begin drip at a rate of 1-4 mg/minute.

9. MORPHINE:
2-4 mg every 5 minutes slowly titrate to control pain.

10. DOPAMINE / LEVOPHED: (per protocol)

To keep SBP>90 mmHg
Dopamine/ Levophed must be administered by a central line access.

IV. CLINICAL EVIDENCE OF REPERFUSION:

A. Prompt relief of pain after thrombolysis

B. Decrease in ST elevation
C. “Reperfusion arrhythmias” -late PVC's or slow VT

V. COMPLICATIONS:

A. If central venous access is required perform cutdown on median basilic vein.

If arterial line required use radial artery-avoid noncompressible vessels.
B. Serious bleeding-
1. Stop thrombolytic and heparin
2. Reverse heparin with protamine sulfate 25 mg IV slowly
3. Recheck PTT
4. Repeat protamine sulfate until PTT is less than 50 seconds
5. Check serum fibrinogen level and replace with cryoprecipitate until greater than
100 mg/dl.
6. Administer 2-3 units fresh frozen plasma
7. Transfuse with packed red blood cells as need to keep Hemoglobin>10.

Prepared by: Dan Clark, MD

Review / approval:
Medicine Cmte: 3/2006
Exec Cmte: 4/2006