Contraindications and Precautions for Fibrinolytic Therapy

Absolute Contraindications

• Active internal bleeding is an absolute contraindication for TPA and TNK, as identified by the FDA label and major cardiology guidelines, including the European Heart Journal 1
• Any history of cerebrovascular accident (intracranial hemorrhage) is an absolute contraindication for TPA and TNK, according to the American College of Cardiology and other guidelines 2

Relative Contraindications

• Significant hypertension on presentation (SBP >180 mmHg or DBP >110 mmHg) is a relative contraindication for TPA and TNK, as recommended by the American Heart Association 2
• History of chronic, severe, poorly controlled hypertension is a relative contraindication for TPA and TNK, according to the European Society of Cardiology 2
• Traumatic or prolonged CPR (>10 minutes) is a relative contraindication for TPA and TNK, as stated by the American College of Cardiology and the European Heart Journal 1, 2
• Active peptic ulcer disease is a relative contraindication for TPA and TNK, according to the European Heart Journal and the American Gastroenterological Association 1, 2

Bleeding Risk Stratification

• Advanced age is an independent predictor of intracranial hemorrhage, as reported by the European Heart Journal 1
• Female gender is an independent predictor of intracranial hemorrhage, according to the European Heart Journal 1
• Prior cerebrovascular disease is an independent predictor of intracranial hemorrhage, as stated by the American College of Cardiology and the European Heart Journal 1, 2
• Elevated blood pressure at presentation is an independent predictor of intracranial hemorrhage, according to the European Heart Journal 1

TNK-Specific Advantages

• TNK (tenecteplase) offers significantly lower rates of non-cerebral bleeding compared to alteplase, as reported by the European Heart Journal 1
• TNK has a lower need for blood transfusion compared to alteplase, according to the European Heart Journal 1

Timing Considerations

• The optimal window for fibrinolytic therapy in STEMI is within 12 hours of symptom onset, as recommended by the American College of Cardiology and the European Society of Cardiology 2
• Fibrinolytic therapy should be used beyond 12 hours only in specific circumstances, such as large area at risk or hemodynamic instability, when PCI is unavailable, according to the American College of Cardiology and the European Society of Cardiology 2

Common Pitfalls to Avoid

• Diabetes or diabetic retinopathy is not a contraindication for fibrinolytic therapy, as stated by the American College of Cardiology and the European Heart Journal 1, 2
• Successful resuscitation is not a contraindication for fibrinolytic therapy, but prolonged or traumatic CPR (>10 minutes) is a relative contraindication, according to the American College of Cardiology and the European Heart Journal 1, 2