Contraindications to thrombolysis

The use of thrombolysis is well known to improve outcomes in patients suffering from a myocardial infarction, pulmonary embolus, stroke and ischemic limb injury. However, the use of recombinant tissue plasminogen activator is not without risks. Therefore, clinicians must select patients who are to be best suited for the procedure, and those who have the least risk of having a fatal complication.

Myocardial Infarction

Absolute Contraindications to Thrombolysis^[1]

• Any previous history of hemorrhagic stroke,ischemic stroke within 3 months.
• History of stroke, dementia, or central nervous system damage within 1 year
• Head trauma within 3 weeks or brain surgery within 6 months
• Known intracranial neoplasm
• Suspected aortic dissection
• Internal bleeding within 6 weeks
• Active bleeding or known bleeding disorder
• Traumatic cardiopulmonary resuscitation within 3 weeks

Relative Contraindications to Thrombolysis^[1]

• Oral anticoagulant therapy
• Acute pancreatitis
• Pregnancy or within 1 week postpartum
• Active peptic ulceration
• Transient ischemic attack within 6 months
• Dementia
• Infective endocarditis
• Active cavitating pulmonary tuberculosis
• Advanced liver disease
• Intracardiac thrombi
• Uncontrolled hypertension (systolic blood pressure >180 mm Hg, diastolic blood pressure >110 mm Hg)
• Puncture of noncompressible blood vessel within 2 weeks
• Previous streptokinase therapy

Major surgery, trauma, or bleeding within 2 weeks

Stroke

Absolute Contraindications to Thrombolysis^[2]

• Uncertainty about time of stroke onset (e.g. patients awakening from sleep).
• Coma or severe obtundation with fixed eye deviation and complete hemiplegia.
• Hypertension: systolic blood pressure ≥ 185mmHg; or diastolic blood pressure >110mmHg on repeated measures prior to study. (if reversed, patient can be treated)
• Clinical presentation suggestive of subarachnoid haemorrhage even if the CT scan is normal.
• Presumed septic embolus.
• Patient having received a heparin medication within the last 48 hours and has an elevated Activated Prothrombin Time (APTT) or has a known hereditary or acquired haemorrhagic diathesis
• INR >1.7
• Known advanced liver disease, advanced right heart failure, or anticoagulation, and INR > 1.5 (no need to wait for INR result in the absence of the former three conditions).
• Known platelet count <100,000 uL.
• Serum glucose is < 2.8 mmol/l or >22.0 mmol/l.

Relative Contraindications to Thrombolysis^[2][3]

• Severe neurological impairment with NIHSS score >22.
• Age >80 years.
• CT evidence of extensive middle cerebral artery (MCA) territory infarction (sulcal effacement or blurring of grey-white junction in greater than 1/3 of MCA territory).
• Stroke or serious head trauma within the past three months where the risks of bleeding are considered to outweigh the benefits of therapy.
• Major surgery within the last 14 days (consider intra-arterial thrombolysis).
• Patient has a known history of intracranial haemorrhage, subarachnoid haemorrhage, known intracranial arteriovenous malformation or previously known intracranial neoplasm
• Suspected recent (within 30 days) myocardial infarction.
• Recent (within 30 days) biopsy of a parenchymal organ or surgery that, in the opinion of the responsible clinician, would increase the risk of unmanageable (e.g. uncontrolled by local pressure) bleeding.
• Recent (within 30 days) trauma with internal injuries or ulcerative wounds.
• Gastrointestinal or urinary tract haemorrhage within the last 30 days or any active or recent haemorrhage that, in the opinion of the responsible clinician, would increase the risk of unmanageable (e.g. by local pressure) bleeding.
• Arterial puncture at non-compressible site within the last 7 days.
• Concomitant serious, advanced or terminal illness or any other condition that, in the opinion of the responsible clinician would pose an unacceptable risk.
• Minor or Rapidly improving deficit.
• Seizure: If the presenting neurological deficit is deemed due to a seizure.
• Pregnancy is not an absolute contraindication. Consider intra-arterial thrombolysis.

References

1. Harvey D. White; Frans J. J. Van de Werf (1998). "Clinical Cardiology: New Frontiers Thrombolysis for Acute Myocardial Infarction". Circulation. 97: 1632–1646. doi:10.1161/01.CIR.97.16.1632.
2. Department of Health, Western Australia. "Protocol for Administering Alteplase in Acute Ischaemic Stroke Guidelines." (PDF). Perth: Health Networks Branch, Department of Health, Western Australia. Retrieved 2013-06-12.
3. Jason Thurman; Edward C. Jauch (2002). "Acute ischemic stroke: emergent evaluation and management". Emergency Medicine Clinics of North America. 20: 609–630. doi:10.1016/s0733-8627(02)00014-7.