Contraindications for Thrombolysis

Absolute Contraindications

• The American College of Cardiology states that previous hemorrhagic stroke at any time or stroke of unknown origin is an absolute contraindication for thrombolysis 1, 2
• The American College of Cardiology recommends that ischemic stroke within the preceding 6 months is an absolute contraindication for thrombolysis 2
• Active internal bleeding, excluding menses, is an absolute contraindication for thrombolysis, as stated by the American College of Cardiology 1, 2
• Recent head trauma or cranial trauma within the preceding 3 weeks is an absolute contraindication for thrombolysis, according to the American College of Cardiology 2
• Severe uncontrolled hypertension, with blood pressure >200/120 mmHg despite treatment, is an absolute contraindication for thrombolysis 2
• Recent major surgery within the preceding 3 weeks is an absolute contraindication for thrombolysis, as stated by the American College of Cardiology 2
• Diabetic hemorrhagic retinopathy is an absolute contraindication for thrombolysis, according to the American College of Cardiology 2

Relative Contraindications

• The American College of Cardiology states that transient ischemic attack within the preceding 6 months is a relative contraindication for thrombolysis 2
• History of prior cerebrovascular accident or known intracerebral pathology is a relative contraindication for thrombolysis, as stated by the American College of Cardiology 1
• Severe uncontrolled hypertension on presentation, with blood pressure >180/110 mmHg but <200/120 mmHg, is a relative contraindication for thrombolysis 1, 2
• Current use of anticoagulants in therapeutic doses, with INR >2-3, is a relative contraindication for thrombolysis, according to the American College of Cardiology 1
• Known bleeding diathesis is a relative contraindication for thrombolysis, as stated by the American College of Cardiology 1, 2
• Recent trauma within 2-4 weeks, including traumatic CPR, is a relative contraindication for thrombolysis 1, 2
• Noncompressible vascular punctures are a relative contraindication for thrombolysis, according to the American College of Cardiology 1, 2
• Pregnancy or within 1 week postpartum is a relative contraindication for thrombolysis, as stated by the American College of Cardiology 2
• Active peptic ulcer disease is a relative contraindication for thrombolysis, according to the American College of Cardiology 1, 2
• Advanced liver disease is a relative contraindication for thrombolysis, as stated by the American College of Cardiology 2
• Infective endocarditis is a relative contraindication for thrombolysis, according to the American College of Cardiology 2
• Large thrombus in left atrium or on prosthesis is a relative contraindication for thrombolysis, as stated by the American College of Cardiology 2
• Prior exposure to streptokinase/anistreplase, especially within 5 days to 2 years, or prior allergic reaction, is a contraindication to reuse any streptokinase-containing agent, according to the American College of Cardiology 1, 2

Critical Context-Dependent Considerations

• In life-threatening situations such as high-risk pulmonary embolism with cardiogenic shock or persistent hypotension, most contraindications become relative rather than absolute, as stated by the American College of Cardiology 2
• Thrombolysis should be administered unless there is active bleeding or recent hemorrhagic stroke, according to the American College of Cardiology 2
• The survival benefit outweighs most bleeding risks in hemodynamically unstable patients, as stated by the American College of Cardiology 2
• Surgical pulmonary embolectomy is the preferred alternative when absolute contraindications exist, according to the American College of Cardiology 2

Risk Factors for Intracranial Hemorrhage

• Advanced age, greater than 65 years or greater than 80 years, increases the risk of symptomatic intracranial hemorrhage, as stated by the American College of Cardiology 1
• Low body weight, less than 67-70 kg, requires dose adjustment for alteplase and increases the risk of intracranial hemorrhage, according to the American College of Cardiology 1
• Hypertension on admission increases the risk of symptomatic intracranial hemorrhage, as stated by the American College of Cardiology 1
• Hyperglycemia, especially greater than 8.4 mmol/L or greater than 180 mg/dL, increases the risk of symptomatic intracranial hemorrhage, according to the American College of Cardiology 2

Important Clinical Caveats

• The dose of alteplase should be adjusted downward for patients weighing less than 67 kg or 65 kg to reduce intracranial hemorrhage risk, as stated by the American College of Cardiology 1
• Aspirin, 160-325 mg, should be given as part of acute MI management, according to the American College of Cardiology 1

Relative Contraindication of Recent Gastrointestinal Bleeding in High‑Risk Pulmonary Embolism

Guideline Principles (European Society of Cardiology)

• The ESC 2008 pulmonary embolism guidelines state that contraindications deemed absolute for acute myocardial infarction (e.g., surgery within the prior 3 weeks or gastrointestinal bleeding within the past month) may be re‑classified as relative when treating a patient with high‑risk pulmonary embolism who faces an immediate risk of death. 3

Classification of Contraindications

• Relative contraindications – infective endocarditis is listed as a relative contraindication in acute myocardial infarction guidelines, but its classification may shift depending on clinical context. 3

Specific Contraindication: Recent Gastrointestinal Bleeding

• In stable patients with acute myocardial infarction, gastrointestinal bleeding that occurred within the preceding month is classified as an absolute contraindication to fibrinolytic therapy. 3
• In patients with high‑risk pulmonary embolism accompanied by hemodynamic instability or cardiogenic shock, the same recent gastrointestinal bleeding becomes a relative contraindication because the potential survival benefit of thrombolysis outweighs the bleeding risk. 3

Clinical Decision Hierarchy

• Massive pulmonary embolism with hemodynamic instability – fibrinolytic therapy should be administered unless there is active bleeding or a recent hemorrhagic stroke; the overall survival benefit supersedes most bleeding risks, making recent gastrointestinal bleeding a secondary consideration. 3
• Less urgent presentation (e.g., acute myocardial infarction without shock) – recent gastrointestinal bleeding remains an absolute contraindication, and the risk‑benefit assessment favors avoiding fibrinolysis. 3

Supporting Evidence

• The 2008 ESC pulmonary embolism guidelines explicitly note that “contraindications to thrombolysis that are considered absolute in acute myocardial infarction, such as surgery within the previous three weeks or gastrointestinal bleeding in the last month, may become relative in a patient with high‑risk pulmonary embolism with an immediate risk of death.” 3