Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
- Ramon Corbalan, MD
Ramon Corbalan, MD
- Professor of Medicine
- Cardiovascular Division
- Pontificia Universidad Catolica de Chile
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- Freek Verheugt, MD, FACC, FESC
Freek Verheugt, MD, FACC, FESC
- Section Editor — Coronary Heart Disease
- Onze Lieve Vrouwe Gasthuis, Netherlands
Most cases of acute myocardial infarction are caused by coronary artery plaque rupture with subsequent thrombus formation. When thrombosis leads to total occlusion of blood flow, acute ST-elevation myocardial infarction (STEMI) is often the clinical outcome. Patients with acute STEMI should receive coronary reperfusion therapy with either primary percutaneous coronary intervention (PCI) or fibrinolysis. Reperfusion improves clinical outcomes in nearly all groups of patients with STEMI who present within 12 hours of symptom onset. (See "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy", section on 'Summary and recommendations'.)
For most patients with acute STEMI, we prefer primary PCI rather than fibrinolysis. However, fibrinolytic therapy, if it can be delivered in a timely manner, should be used if timely primary PCI is not available. Fibrinolytic (thrombolytic) therapy is capable of reestablishing antegrade blood flow in nearly 75 percent of patients, when administered within the first two hours of symptom onset. (See "The role of the vulnerable plaque in acute coronary syndromes", section on 'Plaque features responsible for acute thrombosis' and "Fibrinolytic (thrombolytic) agents in acute ST elevation myocardial infarction: Markers of efficacy", section on 'TIMI flow grade'.)
This topic will discuss the use of fibrinolytic therapy in patients with STEMI. Larger discussions of the clinical trials comparing these agents to placebo or to each other, comparisons with primary PCI, and the management of failed fibrinolysis are found elsewhere. (See "Characteristics of fibrinolytic (thrombolytic) agents and clinical trials in acute ST elevation myocardial infarction" and "Primary percutaneous coronary intervention versus fibrinolysis in acute ST elevation myocardial infarction: Clinical trials" and "Management of failed fibrinolysis (thrombolysis) or threatened reocclusion in acute ST elevation myocardial infarction".)
Our treatment approach to patients with acute ST elevation myocardial infarction who will receive fibrinolytic therapy is as follows:
●Administer orally (if possible): aspirin, clopidogrel, and a statin as soon as possible. We give 325 mg of uncoated aspirin, 300 mg of clopidogrel (75 mg in patients ≥75 years of age), and atorvastatin 80 mg. (See 'Concomitant therapies' below.)
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- OUR APPROACH
- FIBRINOLYSIS VERSUS PRIMARY PCI
- Consultation with a cardiologist
- INDICATIONS FOR FIBRINOLYTIC THERAPY
- USE IN SPECIFIC PATIENT GROUPS
- Elderly patients
- Cardiogenic shock
- Prior MI
- Prior CABG
- Menstruating women
- Diabetes mellitus
- INITIATION OF THERAPY
- Prehospital fibrinolysis
- Choice of agent
- CONCOMITANT THERAPIES
- Anticoagulant therapy
- Antiplatelet therapy
- Beta blocker
- MANAGEMENT AFTER FIBRINOLYSIS
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS