Clinical Review ABC of antithrombotic therapy

Antithrombotic therapy in myocardial infarction and stable angina

BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7375.1287 (Published 30 November 2002) Cite this as: BMJ 2002;325:1287
  1. Gregory Y H Lip,
  2. Bernard S P Chin,
  3. Neeraj Prasad

    Acute Q wave myocardial infarction

    The use of thrombolytic treatment in acute myocardial infarction is now established beyond doubt. However, primary angioplasty is now proved to be an effective alternative and is used increasingly in preference to thrombolysis in many centres worldwide.

    Electrocardiogram indicating acute inferior myocardial infarction

    Thrombolytic treatment

    Current key issues relate to the clinical situations in which thrombolysis may be beneficial or contraindicated. For example, all patients with a history suggesting cardiac ischaemia and accompanying electrocardiographic changes indicating acute myocardial infarction should be considered for thrombolysis. However, patients with only ST segment depression on an electrocardiogram or with a normal electrocardiogram do not benefit from thrombolysis, and treatment should therefore be withheld. Exceptions to this are when there is evidence of new development of left bundle branch block or a true posterior myocardial infarction (shown by ST segment depression with dominant R waves present in leads V1 and V2). These situations require thrombolytic treatment.

    Indications and contraindications for thrombolysis in acute myocardial infarction

    Indications

    • Clinical history and presentation strongly suggestive of myocardial infarction within 6 hours plus one or more of: 1 mm ST elevation in two or more contiguous limb leads 2 mm ST elevation in two or more contiguous chest leads New left bundle branch block 2 mm ST depression in V1-4 suggestive of true posterior myocardial infarction

    • Patients presenting with above within 7-12 hours of onset with persisting chest pains and ST segment elevation

    • Patients aged <75 years presenting within 6 hours of anterior wall myocardial infarction should be considered for recombinant tissue plasminogen activator

    Contraindications

    Absolute
    • Aortic dissection

    • Previous cerebral haemorrhage

    • Known history of cerebral aneurysm or arteriovenous malformation

    • Known intracranial neoplasm

    • Recent (within past 6 months) thromboembolic stroke

    • Active internal bleeding (excluding menstruation)

    • Patients previously treated with streptokinase or anisolated plasminogen streptokinase activator complex (APSAC or anistreplase) should receive recombinant tissue plasminogen activator, reteplase, or tenecteplase

    Relative

    • Severe uncontrolled hypertension (blood pressure …

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