Fibronolytic therapy in ACS

Question 1

Fibrinolytic indication

Answer 1

STEMI (class I when onset of ischemic symptoms is within the previous 12 hours) when it is expected that primary PCI cannot be done within 120 minutes of first medical contact, with an ideal door-to-needle time of less than 30 minutes

Question 2

UFH dose with fibrinolytics in STEMI

Answer 2

60-unit/kg bolus (maximum 4000 units) and 12 units/kg/hour (maximum 1000 units/hour), to obtain an aPTT of 1.5–2.0 times control (about 50–70 seconds) for at least 48 hours

Question 3

Enoxaparin dose with fibrinolytics in STEMI (< 75 years)

Answer 3

30 mg intravenously, followed in 15 minutes by a 1-mg/kg subcutaneous injection every 12 hours for the duration of index hospitalization, for up to 8 days, or until revascularization. Maximum 100 mg for the first two doses.

Question 4

Enoxaparin dose use fibrinolytics (> 75 years)

Answer 4

omit bolus, 0.75 mg/kg subcutaneous injection every 12 hours for the duration of index hospitalization, for up to 8 days, or until revascularization. maximum 75 mg for the first two doses

Question 5

Fondaparinux STEMI dose with fibrinolytics

Answer 5

initial 2.5-mg intravenous dose, followed in 24 hours by 2.5-mg/day subcutaneous injections for the duration of the index hospitalization, for up to 8 days, or until revascularization

Question 6

Alteplase (t-PA, Activase) STEMI dose

Answer 6

≤ 67 kg: 15 mg IVP over 1–2 min, then 0.75 mg/kg IV over 30 min (max 50 mg), then 0.5 mg/kg (max 35 mg) over 60 min
> 67 kg: 15 mg IVP over 1–2 min, then 50 mg over 30 min, then 35 mg over 1 hr (max total dose 100 mg)

Question 7

Reteplase (r-PA, Retavase) dose in STEMI

Answer 7

10 units IVP; repeat 10 units IV in 30 min

Question 8

Tenecteplase (TNK-t-PA, TNKase) dose in STEMI

Answer 8

< 60 kg: 30 mg IVP; 60–69 kg: 35 mg IVP; 70–79 kg: 40 mg IVP; 80–89 kg: 45 mg IVP; ≥ 90 kg: 50 mg IVP (~0.5 mg/kg)

Question 9

Fibrinolytic Absolute Contraindications

Answer 9

Any prior hemorrhagic stroke
Ischemic stroke within 3 mo (except in past 4½ hr)
Intracranial neoplasm or arteriovenous malformation
Active internal bleeding
Aortic dissection
Considerable facial trauma or closed-head trauma in past 3 mo
Intracranial or intraspinal surgery within 2 mo
Severe uncontrolled HTN (unresponsive to emergency therapy)