Fibrinolytic Agent

Dose

Fibrin
Specificity*

Antigen
ic
Patency Rate (90-min TIMI 2 or

Single IV weight-based
bolus

++++

No

85%328

++

No

84%314

90-min weight-based
infusion

++

No

73% to 84%314, 324, 326

1.5 million units IV given

over 3060 min

No

Yes

60% to 68%324, 329

Fibrin-specific:
Tenecteplase (TNKtPA)

10 U + 10-U IV boluses
Reteplase (rPA) given 30 min apart

Alteplase (tPA)
Nonfibrin-specific:

Streptokinase

* Strength of fibrin specificity; ++++ is more strong, ++ is less strong.

30 mg for weight <60 kg; 35 mg for 6069 kg; 40 mg for 7079 kg; 45 mg for 80
89 kg; and 50 mg for 90 kg.

Bolus 15 mg, infusion 0.75 mg/kg for 30 min (maximum 50 mg), then 0.5 mg/kg
(maximum 35 mg) over the next 60 min; total dose not to exceed 100 mg.

Streptokinase is no longer marketed in the United States but is available in other

countries.

Streptokinase is highly antigenic and absolutely contraindicated within 6 mo of

previous exposure because of the potential for serious allergic reaction.

IV indicates intravenous; rPA, reteplase plasminogen activator; TIMI, Thrombolysis In

Myocardial Infarction; TNK-tPA, tenecteplase tissue-type plasminogen activator; and
tPA, tissue-type plasminogen activator.

Absolute contraindications
Any prior ICH
Known structural cerebral vascular lesion (eg, arteriovenous malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 mo
EXCEPT acute ischemic stroke within 4.5 h
Suspected aortic dissection

 Active bleeding or bleeding diathesis (excluding menses)

Significant closed-head or facial trauma within 3 mo
Intracranial or intraspinal surgery within 2 mo
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 mo
Relative contraindications
History of chronic, severe, poorly controlled hypertension
Significant hypertension on presentation (SBP >180 mm Hg or DBP >110
mm Hg)
History of prior ischemic stroke >3 mo
Dementia
Known intracranial pathology not covered in absolute contraindications
Traumatic or prolonged (>10 min) CPR
Major surgery (<3 wk)
Recent (within 2 to 4 wk) internal bleeding
Noncompressible vascular punctures
Pregnancy
Active peptic ulcer
Oral anticoagulant therapy

* Viewed as advisory for clinical decision making and may not be all-inclusive or
definitive.

CPR indicates cardiopulmonary resuscitation; DBP; diastolic blood pressure; ICH,

intracranial hemorrhage; SBP, systolic blood pressure; and STEMI, ST-elevation
myocardial infarction.

Plan of Care
Medications

Resources/Refere

Plan of Care

Resources/Refere

Antithrombotic therapies

Sections 4.4, 5.1, 6.4

Beta blockers

Section 8.1

ACE inhibitors/ARBs/aldosterone antagonists

Section 8.2

Statins

Section 8.3
ESC STEMI Guideline48
ACC/AHA 2012 SIHD Guideline614

Physical activity/cardiac rehabilitation

Physical activity

AHA/ACC 2011 Update: Secondary Prevention

Cardiorespiratory fitness (MET capacity)

AACVPR/ACCF/AHA 2010 Update: Performance

Rehabilitation616

Risk factor modification/lifestyle interventions

AHA/ACC 2011 Update: Secondary Prevention

Smoking Cessation

ACCP Tobacco Cessation Toolkit615

Diet/nutrition

AHA/ACC 2011 Update: Secondary Prevention

Management of comorbidities

Overweight/obesity

AHA/ACC 2011 Update: Secondary Prevention

Lipids

AHA/ACC 2011 Update: Secondary Prevention

Hypertension

NHLBI National Hypertension Education Progra

Diabetes

AHA/ADA CVD Prevention in DM Patients618

HF

ACC/AHA/HFSA HF Guideline619

Arrhythmia/arrhythmia risk

ACC/AHA/HRS DBT & AF Guidelines496,501

Psychosocial factors
Sexual activity

AHA Scientific Statement on Sexual Activity an

Gender-specific issues

Cardiovascular Disease Prevention in Women G

Depression, stress, and anxiety

AHA Scientific Statement on Depression 621

Alcohol use

AHA/ACC 2011 Update: Secondary Prevention

Plan of Care

Resources/Refere

Culturally sensitive issues

Provider follow-up
Cardiologist

H2H Quality Initiative http://www.h2hquality.or

Primary care provider

Advanced practice nurse/physician assistant
Other relevant medical specialists
Electronic personal health records
Influenza vaccination

Centers for Disease Control Adult Vaccinations

Patient/family education
Plan of care for acute MI

AHA CPR Guideline201

Recognizing symptoms of MI
Activating EMS, signs and symptoms for urgent vs emergency
evaluations
CPR Training for family members
Risk assessment & prognosis
Advanced directives
Social networks/social isolation
Socioeconomic factors
Access to health insurance coverage
Access to healthcare providers
Disability
Social services
Community services

http://www.qualityforum.org/Topics/Care_Coord