Fibrinolyse: Medikamente,

Indikationen, Komplikationen

Prof. Dagmar Keller LangDirektorin, Institut für Notfallmedizin

21. St.Galler IPS-Symposium,10.1.2017

Fibrinolyse Indikationen

STEMI

Stroke

Lungenembolie

ST-segment elevation at the J point in

• two contiguous leads and ≥0.25 mV in men below the age of 40 years

• ≥0.2 mV in men over the age of 40 years, or ≥0.15 mV in women in leads

V2–V3 and/or ≥0.1 mV in other leads

STEMI: Typical ECG presentation

STEMI: Atypical ECG presentatioin

LBBB

Ventricular paced rhythm

Patients without diagnostic ST-segment elevation but persistent ischaemic

symptoms

Isolated posterior myocardial infarction

ST-segment elevation in lead aVR

STEMI: Delays

ESC guidelines STEMI, 2012

STEMI: Prehospital

ESC guidelines 2012:

• Evidence that properly trained paramedical personnel can effectively identify

AMI and provide timely reperfusion

• Paramedics trained to administer thrombolytics do so safely and effectively

• Since pre-hospital thrombolysis is an attractive therapeutic option in patients

presenting early after symptom onset, especially when transfer time is

prolonged, ongoing training of paramedics to undertake these functions is

recommended, even in the era of primary PCI

STEMI: Fibrinolysis Recommendation

USZ cardix: “long distance” to PCI center

STEMI: Fibrinolytic agents

USZ cardix: Alteplase (Actilyse)

> 65 kg KG: 15 mg Bolus iv, 50 mg iv over 30 min, 35 mg iv over 60 min

or: 15 mg Bolus iv, 0.75mg/kg iv in 30 min, 0.5 mg/kg iv over 60 min

STEMI: Antithrombotic co-therapy

USZ cardix: LMWH sc with normal renal function

UFH bolus 60 IE (max 5000 IE) and weight adapted (12 IE/kg/h)

Anti-Xa control

STEMI: Interventions following fibrinolysis

STEMI: Thrombolytic therapy complications

Bleeding risk major and minor:

- Correct contraindication to thrombolysis

- Anti-thrombin co-therapy

- PCI after thrombolysis failure, additional anti-platelet co-therapy

Stroke: AHA/ASA Guidelines 2013, update 2015

Update 2015:

4.5 h

Stroke: AHA/ASA Guidelines 2013

Stroke: Endovascular thrombectomy

Metaanalysis: Goyal et al., Lancet 2016:

“Endovascular thrombectomy is of benefit to most patients with

acute ischaemic stroke caused by occlusion of the proximal anterior

circulation, irrespective of patient characteristics or geographical location.

Global implications on structuring systems of care to provide timely

treatment to patients with acute ischaemic stroke due to large vessel

occlusion”

Stroke: Endovascular thrombectomy

2015 AHA/ASA Focused Update of the 2013 Guidelines:

Patients eligible for intravenous r-tPA should receive intravenous r-tPA even if

endovascular treatments are being considered (Class I; Level of Evidence A)

(unchanged from the 2013 guideline)

Patients should receive endovascular therapy with a stent retriever if they meet all the

following criteria (Class I; Level of Evidence A). (New recommendation):

(a) prestroke mRS score 0 to 1,

(b) acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset

according to guidelines from professional medical societies,

(c) causative occlusion of the internal carotid artery or proximal MCA (M1),

(d) age ≥18 years,

(e) NIHSS score of ≥6,

(f) ASPECTS of ≥6, and

(g) treatment can be initiated (groin puncture) within 6 hours of symptom onset

”

Stroke: Thrombolytic therapy complications

Recombinant tissue-type plasminogen activator (r-tPA)

Recombinant tissue-type plasminogen activator (r-tPA) and endovascular

thrombectomy

http://www.google.ch/url?sa=i&rct=j&q=pulmonary+embolism+echocardiogram&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://medandlife.ro/medandlife431.html&ei=-0LrVOm7G4naOPHigIAI&bvm=bv.86475890,d.ZGU&psig=AFQjCNFRZisL531YmsVTpIky8i0pPFpAzg&ust=1424790646758282

Pulmonary Embolism

PE: Risk factors

ESC Guidelines 2014

PE: Risk factors

ESC Guidelines 2014

PE: Diagnostic tests

D-Dimere

CT Thorax

TTE

Doppler US

Szintigrafie

MRI

PE: High risk situation

ESC Guidelines 2014

PE: High risk situation

ESC Guidelines 2014

PE: Fibrinolysis recommendation

Jaff M R et al. Circulation. 2011;123:1788-1830

PE: Fibrinolysis recommendation with shock

Jaff M R et al. Circulation. 2011;123:1788-1830

PEITHO Trial 2013

PE: Fibrinolysis without shock

PE: PEITHO Trial

Meyer et al, NEJM 2014

PE: PEITHO Trial

PEITHO Trial 2013 Summary

PE: Fibrinolysis without shock

Normotensive patients with intermediate-risk pulmonary embolism:

composite primary outcome of early death or hemodynamic decompensation

was reduced after treatment with a single intravenous bolus of tenecteplase.

Tenecteplase was associated with a significant increase in the

risk of intracranial and other major bleeding.

Great caution is warranted when considering

fibrinolytic therapy for hemodynamically stable patients with pulmonary

embolism, right ventricular dysfunction, and positive cardiac troponin

PE: Fibrinolysis without shock

Meyer et al, NEJM 2014

PE: EKOS (Eko-Sonic Endovascular System)

PE: EKOS

PE: EKOS ULTIMA trial

PE: EKOS ULTIMA trial

PE: EKOS ULTIMA trial

Fibrinolyse: «considered» Class IIb

Alternatives:

- Surgical embolectomy

- Katheter-based intervention (EKOS)

- Cava filter

PE: Therapy post cardiac arrest

PE: Contra-indications fibrinolysis

ESC Guidelines 2014

PE: Thrombolytic therapy complications

Major bleeding and

intracranial bleeding

in prospective trials

Daley et al. Therapeutic Advances in Drug Safety 2014

PE: Thrombolytic therapy complications

Known risk factors for major bleeding following thrombolytic therapy for acute PE

Daley et al. Therapeutic Advances in Drug Safety 2014

PE: Thrombolytic therapy complications

Strategies to minimize bleeding risk

• Contraindications

• Dosing consideration

• Administration technique

• Reperfusion strategy:

• Systemic fibrinolysis

• Catheter-based reperfusion therapy (EKOS)

• Cave: ECMO after EKOS

PE: www.Notfallstandards.ch

PE: www.Notfallstandards.ch

Danke für die Aufmerksamkeit