11. When is fibrinolytic therapy indicated at a facility not capable of percutaneous coronary intervention?

A. In a 45 year old male with 2 mm ST depression in the inferior leads and a troponin of 35

B. A 55 year old male with a malignant intracranial tumor and an anterior ST segment elevation myocardial infarction

C. A 77 year old female with an ischemic stroke 2 months prior now with an anterior ST segment elevation myocardial infarction

D. A 35 year old male admitted with a motor vehicle accident and significant head trauma now with an anterior ST elevation myocardial infarction

E. A 42 year old menstruating female with an inferior ST elevation myocardial infarction

Menstruation is not a contraindication to fibrinolytic therapy. Choice A describes a non-ST elevation myocardial infarction and fibrinolytic therapy is not indicated in this setting. Choices B, C and D all describe situations that are absolute contraindications for fibrinolytic therapy.

When the decision to treat a STEMI patient with fibrinolytic therapy is made (since 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 of intracranial hemorrhage (ICH) defined as  > 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:

1. Prior intracranial hemorrhage
2. Ischemic stroke within 3 months
3. Known cerebrovascular abnormality such as aneurysm or arteriovenous malformation
4. Known malignant intracranial tumor
5. Significant closed head trauma or facial trauma within 3 months

Relative contraindications (not absolute) to fibrinolytic therapy include:

1. Uncontrolled hypertension (blood pressure > 180/110) either currently or in the past
2. Intracranial abnormality not listed as absolute contraindication (i.e. benign intracranial tumor).
3. Ischemic stroke > 3 months prior
4. Bleeding within 2-4 weeks (excluded menses)
5. Traumatic or prolonged cardiopulmonary resuscitation (CPR)
6. Major surgery within 3 weeks
7. Pregnancy
8. Current use of anticoagulants
9. Non-compressible vascular puncture
10. Dementia

Note that advanced age is not listed as an absolute or relative contraindication to fibrinolytic therapy in the ACC/AHA guidelines.