Clinical indications for consideration of the use of thrombolytic therapy are as follows:
Deep venous thrombosis—Thrombolytics have been used for the treatment of acute, large DVTs; thrombolytics produce complete or near-complete lysis of clots, superior to that seen when heparin is used alone. There is a decreased incidence of postphlebitic syndrome and lower extremity ulcers. Some studies show an increased risk of hemorrhagic complications up to three times that seen with heparin alone, so patients must be selected carefully.
Acute myocardial infarction—Vascular reperfusion is the major determinant of improved clinical outcome and mortality reduction. The best results are found in patients with recent onset of chest pain (less than 6 h). Thrombolytics are administered systemically or by intracoronary injection.
Pulmonary embolism—The role of thrombolytic therapy in patients with pulmonary embolism is not clearly defined; however, it should be considered in patients with acute onset of symptoms (<48 h), evidence of hemodynamic compromise, presence of massive emboli, or the presence of submassive emboli superimposed on chronic cardiopulmonary disease. Patients with pulmonary embolism who receive thrombolytic therapy have greater reperfusion, earlier normalization of the perfusion scan, and decreased pulmonary artery pressures, although no clinical trial has confirmed improved survival.
Peripheral arterial occlusion—Acute peripheral arterial occlusions as well as those in some central sites are commonly treated with systemic or intra-arterial infusion of thrombolytic agents. In this setting, urokinase may be superior to streptokinase.
Acute ischemic stroke—Until recently, no clinically effective therapy for acute ischemic stroke has been available. Several multicenter randomized clinical trials have studied the use of r-tPA for the treatment of acute ischemic stroke in progress. The best outcome occurs when treatment is initiated within 3 h of the onset of symptoms in carefully selected patients. Patients treated with r-tPA have an improved neurologic outcome at 3 months, although there is an increased risk (three to nine times compared with placebo) of intracranial hemorrhage.
Specific recommendations for the use of thrombolytic agents in various clinical settings are available in Chapter216. Many institutions have protocols for the use of thrombolytic agents. Contraindications to use the thrombolytic therapy are outlined in I§b!eii211-10..
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