THROMBOLYSIS FOR STEMI

IN
TAMALE TEACHING HOSPITAL

Abdul-Subulr Yakubu
BSc, MB ChB, PG Cert (Interv. Cardiol.), FGCP, FWACP
Outline
◦ Overview of ACS
◦ Reperfusion therapy- thrombolysis
◦ Practical approach
◦ Team work
Most cases of acute myocardial infarction are caused by coronary artery plaque rupture with subsequent
thrombus formation.
 Aims
◦ Prevent death

◦ Limit the extent of myocardial damage

◦ Minimise patient’s discomfort and distress

‘TIME IS Strategy
MUSCLE!’ ◦ Re-establish myocardial reperfusion before irreversible
damage occurs mechanically (PPCI, primary percutaneous
coronary intervention)

◦ pharmacologically (induction of thrombolysis by

thrombolytic agent)

◦ pharmaco-invasive (combination of pharmacological and

mechanical intervention)

Steg et al. Eur Heart J 2012;33:2569-2619.

 ◦ The benefits of reperfusion decline rapidly
with time

Boersma et al. Lancet 1996;348:771-775.

Reperfusion treatments

Mechanical Pharmacological Pharmaco-invasive

reperfusion reperfusion therapy

Primary percutaneous Pre-hospital / in-hospital Thrombolysis followed

coronary intervention thrombolysis (PHT / by early angiography and
(PPCI) IHT) mechanical intervention
if indicated

Time is critical for STEMI management!

Organised STEMI networks can be an invaluable asset in enabling
STEMI patients to undergo coronary reperfusion in a timely manner
Guidelines
 Evolution of therapy in STEMI and acute ischemic stroke.

Elgendy IY et al. Evolution of acute ischemic stroke therapy from lysis to thrombectomy: similar or
different to acute myocardial infarction?. International journal of cardiology. 2016 Nov 1;222:441-7.
THROMBOLYTIC
AGENTS

◦ Fibrin specific
◦ Alteplase
◦ Reteplase
◦ Tenecteplase

◦ Fibrin non-specific
◦ Streptokinase
◦ Urokinase
◦ Anistreplase
The ideal thrombolytic agent
Rapid acting

High efficacy in terms of both 60-90 minute vessel patency (TIMI grade flow)

Low incidence of adverse reactions, particularly bleeding and stroke

Low re-occlusion rate

Easy to administer (bolus vs. infusion)

Simple, patient-tailored dosage regimen

Good long-term effects on clinical outcome

Cost-effective

1. Van de Werf. Eur Heart J 1999;20:1452-1458.

◦ 51 yo male, known
DM/HTN with sudden
onset left-sided chest pain
at 6 am
Important
timelines
from
international
guidelines
Initial therapy
◦ ABC, IV access + initial labs, ECG monitoring
◦ O2 if hypoxic
◦ Aspirin
◦ P2Y12-i (Clopidogrel)
◦ Nitrates, Morphine if necessary and no CI
◦ Anticoagulation
◦ Statins
◦ Beta blockers
Some guidelines
 Complications
Independent predictors of ICH:
◦ The most common site for ◦ Age ≥75 years
spontaneous bleeding is the ◦ Being from a Black population
GIT ◦ Female sex
◦ Hemorrhagic stroke is the ◦ Prior history of stroke
greatest concern. ◦ Systolic blood pressure ≥160 mmHg
◦ GUSTO-I found a 1.8 percent ◦ Weight ≤65 kg for women or ≤80 kg for men
incidence of severe bleeding1The ◦ International normalized ratio >4 or
majority of strokes (95 percent) prothrombin time >24 seconds
occurred within five days of
◦ Use of alteplase
therapy

1Berkowitz SD et al Incidence and predictors of bleeding after contemporary thrombolytic therapy for myocardial infarction. The Global Utilization of
Streptokinase and Tissue Plasminogen activator for Occluded coronary arteries (GUSTO) I Investigators. Circulation. 1997 Jun 3;95(11):2508-16. doi:
10.1161/01.cir.95.11.2508. PMID: 9184581.
◦ Suspect ICH:
sudden neurological deterioration
decline in the level of consciousness
new headache
nausea and vomiting
sudden rise in blood pressure after fibrinolytic therapy, especially within the first 24 hours of
treatment.

◦ The central steps in the early management of suspected ICH are as follows:
Fibrinolytic, antiplatelet, and anticoagulant therapies should be discontinued.
An emergent non-contrast head CT or MRI
A neurology and/or neurosurgery consultation should be obtained
Team work
◦ Doctors
◦ Nurses
◦ Pharmacist
Thank you
◦ 2017 ESC guidelines on AMI-STEMI
◦ www.metalyse.com
◦ Steg et al. Eur Heart J 2012;33:2569-2619
◦ Van de Werf. Eur Heart J 1999;20:1452-1458
◦ UpToDate/Medscape