A 68-year-old male with a history of hypertension, diabetes and a prior stroke from an intracranial hemorrhage complains of 9/10 chest pain and shortness of breath. The pain radiates to his right arm and mid-epigastric area. He is diaphoretic as well. His temperature is 99.8, blood pressure 160/90 mm Hg, respirations 20 per minute, heart rate 70 beats per minute and oxygen normal on room air. Physical examination reveals an S4 heart sound and no murmurs. Chest X-ray is normal. His ECG is below:
The nearest facility that can perform percutaneous coronary intervention (PCI) is 120 minutes away. Which of the following is the best option at this time?
A. Give fibrinolytic therapy along with standard medical therapy as a bridge to transfer to a PCI facility (facilitated PCI)
B. Give fibrinolytic therapy along with standard medical therapy without plan for PCI depending on the patient’s response
C. Standard medical therapy only without fibrinolytics without transfer to a PCI facility
D. Standard medical therapy without fibrinolytics and then transfer the patient to a PCI facility
When the decision to treat a patient experiencing a STEMI with fibrinolytic therapy is made because primary PCI is not available in a timely fashion, contraindications to fibrinolytic therapy must be considered. Suspected aortic dissection, active bleeding (excluding menses) or a bleeding diathesis are contraindications to fibrinolytic therapy. In general, if there is high risk for intracranial hemorrhage, or ICH, defined as greater than 4%, then fibrinolytic therapy is contraindicated, as well, and primary PCI is preferred (class I).
The following would place a patient in the high ICH risk category:
Prior intracranial hemorrhage
- Ischemic stroke within 3 months
- Known cerebrovascular abnormality such as aneurysm or arteriovenous malformation
- Known malignant intracranial tumor
- Significant closed head trauma or facial trauma within 3 months
Relative contraindications (not absolute) to fibrinolytic therapy include the following:
Uncontrolled hypertension (blood pressure > 180/110 mm Hg) either currently or in the past
- Intracranial abnormality not listed as absolute contraindication (i.e. benign intracranial tumor)
- Ischemic stroke > 3 months prior
- Bleeding within 2 to 4 weeks (excluded menses)
- Traumatic or prolonged cardiopulmonary resuscitation (CPR)
- Major surgery within 3 weeks
- Current use of anticoagulants
- Non-compressible vascular puncture
Note that advanced age is not listed as an absolute or relative contraindication to fibrinolytic therapy in the American College of Cardiology/American Heart Association guidelines.
When fibrinolytic therapy is not able to be used, transfer to a PCI facility for primary PCI is recommended.