Thrombolysis in STEMI

• Patients with STEMI and onset of symptoms within 12 hours if PCI delay > 120 minutes (class I)
• Patients with STEMI and onset of symptoms between 12-24 hours if continued symptoms or ECG changes and PCI unavailable (class IIa) 

 Door to needle time <30 minutes
 Not indicated for patients with ST depression

Absolute contraindications for fibrinolytic use in STEMI include the following:^[16]

• Prior intracranial hemorrhage (ICH)
• Known structural cerebral vascular lesion
• Known malignant intracranial neoplasm
• Ischemic stroke within 3 months
• Suspected aortic dissection
• Active bleeding or bleeding diathesis (excluding menses)
• Significant closed head trauma or facial trauma within 3 months
• Intracranial or intraspinal surgery within 2 months
• Severe uncontrolled hypertension (unresponsive to emergency therapy)
• For streptokinase, prior treatment within the previous 6 months

Relative contraindications for fibrinolytic use in STEMI include the following:^[16]

• History of chronic, severe, poorly controlled hypertension
• Significant hypertension on presentation (systolic blood pressure > 180 mm Hg or diastolic blood pressure > 110 mm Hg
• Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation (CPR) or major surgery less than 3 weeks previously
• History of prior ischemic stroke not within the last 3 months
• Dementia
• Recent (within 2-4 weeks) internal bleeding
• Noncompressible vascular punctures
• Pregnancy
• Active peptic ulcer
• Current use of an anticoagulant (eg, warfarin sodium) that has produced an elevated international normalized ratio (INR) higher than 1.7 or a prothrombin time (PT) longer than 15 seconds