fibrinolyse: medikamente, indikationen, komplikationen. dr... · stemi: prehospital esc guidelines...
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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
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