Issues in Thrombolysis

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Issues in Thrombolysis

• Dr Richard Loffhagen
• Consultant in Emergency Medicine

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Aim to cover

• Why thrombolyse?
• When thrombolyse?
• Who to thrombolyse?
• Why this may affect you
• The future
• Questions at any time please

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Why thrombolyse - history?

• Acute MIs - Initial trials 80s / 90s
• Aspirin 25 mortality benefit
• Thrombolysis 25 mortality benefit
• Aspirin thrombolysis 50 mortality benefit
• Streptokinase .TPA.bolus agents

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Who to thrombolyse?

• Evidence is based on ECG changes
• ST elevation 1mm in 2 consecutive limb leads
• ST elevation 2mm in 2 consecutive chest leads
• New onset LBBB
• Posterior changes tall R wave V1 V2 and ST
  depression
• PAIN HISTORY

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Contraindications

• Bleeding disorders
• Previous Cerebral Haemorrhage
• Any recent stroke
• Recent surgery
• Previous thrombolysis no longer a problem

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When to thrombolyse

• As early as possible
• Thrombolysis at 4-6 hours post symptoms overall
  mortality is DOUBLED compared to 1-2 hours
• Door to needle targets 30mins
• But what about pain to needle 140mins
• In ambulance thrombolysis now common
• In GP surgery thrombolysis?

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Adverse effects

• Acute ICH
• 0.6 in lt65s
• 3.5 ingt75s
• Of these 60 will die

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Sometimes its easy
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Sometimes less so
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Bear traps especially in young

• Pericarditis
• High take off
• Benign early repolarisation
• Brugada syndrome
• Many others see BMJ series April 2002

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Current therapy

• Oxygen
• Nitrates/ Morphine
• Aspirin 300
• Clopidogrel 600
• Thrombolytic
• Heparin

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Current therapy

• Oxygen
• Nitrates/ Morphine
• Aspirin 300mg
• Clopidogrel 600mg
• Thrombolytic
• Heparin
• What can be done in your GP surgery

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Primary angioplasty (PCI)

• DANAMI-2 NEJM 2003349733-42
• 1500 pts
• End point death, CVA, reinfarct at 30days
• PCI 8.5/Thrombolysis 14 p0.002
• No benefit Mortalityyet
• Big reduction secondary MIs
• Most who are thrombolysed subsequently had
  angio/- plasty

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The future

• PCI networks 24 hr angio service, at specialist
  centres
• Ambulance crews bypass local AE and head to
  angio centre

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Any Questions?
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Summary

• Pre-hospital Thrombolysis
• History, pain and ECG changes
• This may affect you
• PCI networks