Exam 1: Thrombolytics

Question 1

Class: Thrombolytics
Drugs:

Answer 1

• alteplase (tPA)
• Tenecteplase (TNK, TNKase)
• reteplase (Retavase)

Question 2

Class: Thrombolytics
Drug: alteplase (tPA)
MOA:

Answer 2

• Binds w/plasminogen → PLASMIN (enzyme)

• Digests fibrin, fibrinogen, + other clotting factors

Question 3

Class: Thrombolytics
Drug: alteplase (tPA)
Indications:

Answer 3

1st line → AIS
2nd/3rd → Acute MI, PE

Cathflow Activase → line occlusion

AIS:
- Evidence w/i 3hrs 
○4.5 off label
○ AND
- Exclude ICH via CT
- **only drug approved for stroke (0-3 hr window)

PE:
- Hemodynamically unstable w/confirmed PE
○OR
- Hemodynamically stable w/confirmed PE AND RV dysfunction on ECG
○OR
- Unstable w/ ↑clinical index of suspicion, esp if RV dysfuction on ECG

MI → **cath lab
- Acute chest pain <12 hrs w/ >1mm ST elevation in 2 contiguous leads
○OR
- Acute chest pain in setting of new or presumed new left BBB on ECG
○ AND
- Unable to perform PCI w/I 90mins of 1st medical contact

Question 4

Class: Thrombolytics
Drug: alteplase (tPA)
Contraindications:

Answer 4

• ANTICOAGULANTS
• current ICH
• Subarachnoid H
• Active internal bleeding
• 3mo head trauma
• bleeding diathesis
  • <100,000 pltlts
  •INR>1.7
  • aPTT > 40s
  • PT > 15s
  • Hx Warfarin + INR > 1.7
  • Heparin w/i 24hr
  • Direct thrombin inhibitors
  • Direct factor Xa inhibitors
• uncontrolled HTN

Question 5

Class: Thrombolytics
Drug: alteplase (tPA)
Side effects:

Answer 5

• Bleeding → **ICH
  • ↑ risk w/anticoagulants
  • Bedrest x 24hrs
• Angioedema
  • ↑risk w/ACE inhibitors

**CLOSE MONITORING
- ↑BP → ↑ bleed
○ <180/105
- VS + Neuro checks
- Recent wounds, needle punctures, surgeries
- Avoid invasive procedures

• ANGIOEDEMA
  ○Mouth/tongue swelling
  ○STOP

Question 6

Class: Thrombolytics
Drug: alteplase (tPA)
Route/dosing:

Answer 6

• *time critical, sooner the better
• weight-based dosing

- Almost always IV 
○ 60-90 mins
○ 10%bolus
○90% over 1 hr 
- Off label IA (intraarterial)

STROKE
- Dissolve clot
- IV / IA
- Best if w/I 90 mins
○Up to 3hrs
- Off-label → 4.5 hrs
- 30% → minimal / no disability at 3 mo
- ICU = 24hr minimum 

**Requires mixing → DON’T
SHAKE