Consider Thrombolytics in ST-Elevation Myocardial Infarction if Percutaneous Coronary Intervention is not Available or Delayed
Julius Cuong Pham MD
Case
Mr. AMI is a 66-year-old male who is postoperative day number one after hip replacement surgery and complains of acute onset of chest pain and shortness of breath. An electrocardiogram (ECG) is performed that shows new ST-segment elevation in leads II, III, and aVF. You are alone in Community General Hospital, which does not have a percutaneous coronary intervention (PCI) team. As you begin treatment, you recall that Good Heart University Hospital has a PCI team and that door-to-catheterization-table time from your hospital to theirs is 90 minutes. You administer oxygen, nitroglycerin, morphine, aspirin, metoprolol, and heparin and contemplate your next step.
Discussion
ST-elevation myocardial infarction (STEMI) is a myocardial infarction usually associated with acute plaque rupture and occlusion of a coronary artery. In addition to the therapies described earlier, patients with STEMI require immediate reperfusion therapy. This can be achieved with either thrombolytic therapy or percutaneous coronary intervention. Upon identification of STEMI, the practitioner should consider the following.
General Guidelines
Generally, thrombolytics are more effective if given earlier. If presentation is within 3 hours from symptom onset, there is no preference between thrombolytic or percutaneous coronary intervention therapy. After 3 hours PCI (when available) is preferred over thrombolytics.
Generally, when the risk of mortality is high, PCI is preferred over thrombolytics.
The higher the patient’s risk of bleeding with thrombolytic therapy, the more strongly the decision should favor PCI.
When the differences in time for door to balloon and door to needle is less than 1 hour, PCI is preferred.
Indications for Thrombolytic Therapy (All Required)
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