docnikki
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selective agents---> alteplase, reteplase, tenecteplase
nonselective agents---> streptokinase, urokinase, anistreplase.
Which ones do we give in STEMI?
and what about UFH ( unfractionated heparin)...do we give UFH only along with selective fibrinolytics and not nonselective ones unless the risk of systemic thromboembolism is very high......if so why? can we plz discuss this..its imp. thanks.
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| Adam
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I know that tPA is better than streptokinase in STEMI, unless it's contraindicated.
We get better benifits by combination therapy of Heparin and tPA (or ther selective ones).
Heparin is NOT used with Striptokinase.. why?? I need to read about that !!
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| farnsworth
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good question.
I don't know. What would be the rationale to use nonselective fibrinolytics? Used tenecteplase a few times in the pre-clinical setting, but as a rescue measure (CPR with strong suspicion for myocardial infarction, so heparin and aspirin were given concomitantly). In the urban setting an angiography lab is usually available in less than 90min (in the city I lived you could call the cardiologist on call on his cell phone and bypass the emergency room for PTCI resulting in excellent needle-to-balloon times)
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| docnikki
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good input adam and farnsworth..thanks...plz post anything else that you come across in this regard on this thread..I will too..thanks again.
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| docnikki
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farnsworth I think you meant door to balloon time being excellent in an urban setting...right? So in this case the patient gets PTCI within the time frame...and in that case the pt will no longer need thrombolytics obviously..but we will give him aspirin ( indefinitely)PLUS clopidogrel( for one month) PLUS GP IIb/IIIa inhibhitor( I dont know for how long) ..right?...no heparin in this case then?
thanks.
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| farnsworth
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docnikki: in some countries in Europe an emergency physician is sent out together with paramedics in cases where it is likely that the patient's conditions warrants it (multiple trauma injury, severe head injury, status asthmaticus, myocardial infarction etc).
For example: a patient calls the emergency number complaining of dyspnea, chest pain (w/ or w/o radiation...). Paramedics are alarmed and additionally an emergency physician. The physician is brought to the patient by a fast car (in more rural regions sometimes by helicopter), so he might even arrive before the paramedics. So on arrival the patient gets the usual treatment (oxygen, monitoring: BP, HR, SpO2, glucose, an IV line, in case of chest pain: 12lead ECG). If a MI is likely (clinical diagnosis + ECG), the patient will also receive iv aspirin, heparin, nitroglycerin, morphine, inotropes, furosemide, CPAP, etc.
If this happens somewhere where a PTCI lab is available within the next 90min, the patient is directly transferred to a catheter lab (as I mentioned before: in some hospitals once you made the diagnosis, you call the cardiologist on call on his cell phone and bypass the emergency room and bring the patient directly to the catheter lab, where the cardiologist and the cardio team is waiting for you and your patient to do a coronary angiogram).
If not PTCI lab is availabe and the clinical presentation and the ECG suggests an myocardial infarction, you also give tenecteplase, before transportation to the hospital. Heparin is given anyway, regardless whether you give tenecteplase (Metalyse (R)) or not.
After the PTCI the patient is given clopidogrel (loading dose 300mg, maintenance dose 75mg/d) and an GPIIb/IIIa inhibitor.
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| docnikki
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thanks so much dear. that was very very helpful.
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| docnikki
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Farnsworth I have another quest.
If recurrent ST elevation occurs after an initiaal fibrinolytic therapy then the patient must be considered for a rescue angioplastly. but if the procedure cannot be accomplished in a timely fashion then patient can be treated with additional doses of rt-PA or r-PA. but is there a time period that we must wait after the previous fibrinolytic therapy to start the additional one...I read some where 24hrs...why is this so? thanks again.
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| docnikki
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its written that patient can be treated 24hrs after the initial fibrinolytic therapy with additional doses of Rt-PA or r-PA.
I hope i interpreted that correctly.
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