Fibrinolytic therapy in acute ST elevation myocardial infarction: Initiation of therapy
- Thomas Levin, MD
Thomas Levin, MD
- Illinois Heart and Vascular
- Chicago, Illinois
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
Plaque rupture and subsequent thrombus formation play a major role in the genesis of acute coronary occlusion. The introduction of fibrinolytic (thrombolytic) therapy was a major advance in the treatment of acute ST elevation myocardial infarction (STEMI), since over 90 percent of such patients have complete occlusion of the culprit artery due to thrombus. (See "The role of the vulnerable plaque in acute coronary syndromes", section on 'Plaque features responsible for acute thrombosis'.)
However, primary percutaneous coronary intervention (PCI) became the preferred reperfusion strategy for most patients with STEMI, as randomized trials have consistently shown better outcomes such as mortality and lower rates of recurrent ischemia and major complications such as intracranial hemorrhage. (See "Primary percutaneous coronary intervention versus fibrinolysis in acute ST elevation myocardial infarction: Clinical trials".)
Nevertheless, due in part to limited availability of timely primary PCI, fibrinolysis remains an important reperfusion strategy in many locations. (See "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy".)
This topic will discuss the clinical 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 percutaneous coronary intervention, markers of efficacy, 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 "Fibrinolytic (thrombolytic) agents in acute ST elevation myocardial infarction: Markers of efficacy" and "Management of failed fibrinolysis (thrombolysis) or threatened reocclusion in acute ST elevation myocardial infarction".)
Fibrinolytic therapy has largely not been effective in patients with a non-ST elevation MI (NSTEMI). This issue is also discussed separately.
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- INITIATION OF THERAPY
- Choice of agent
- Referral to a specialist
- USE IN SPECIFIC PATIENT GROUPS
- Prior MI
- Prior CABG
- Menstruating women
- Diabetes mellitus
- Absolute contraindications
- Relative contraindications
- - Prior stroke
- - Patient age
- CONCOMITANT THERAPIES
- - Predictors
- - Diagnosis and treatment
- MANAGEMENT AFTER FIBRINOLYSIS
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS