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Home , Alteplase, Tenecteplase

Thrombolytic regimens for acute ST elevation

Primary PCI should be delivered as the default therapy for patients with pain of <12 hours and ST elevation.

Thrombolysis is not a preferred option but may be considered on a case-by-case basis for unstable patients with coronavirus pneumonia who develop a STEMI. Patients with significant co-morbidity to be discussed on a case-by-case basis.

Drug Recommended IV regimen Advantages, limitations and other information  Less non-cerebral and need for transfusion; Single IV bolus over 10 seconds based upon easier to administer (single bolus due to longer half- body weight: life) both in and out of hospital; these advantages make Tenecteplase the drug of choice in many <60 kg: 30 mg (6,000 units) hospitals.

60 to 69 kg: 35 mg (7,000 units)  Initiated within 6 hours of symptoms onset.

+ + +  10,000 units = 50mg. 70 to 79 kg: 40 mg (8,000 units) (Enoxaparin) 80 to 89 kg: 45 mg (9,000 units) A half dose of Tenecteplase should be considered in patients ≥ 75yrs old. ≥90 kg: 50 mg (10,000 units)

15 mg bolus  In patient >65kg use 15mg bolus, then 50mg over 30min IV infusion, then 35mg over 60 min IV infusion. then 0.75 mg/kg (maximum 50 mg) over 30 (accelerated regimen) minutes (IV infusion)  Accelerated regimen should be used within 6 hours of symptoms onset. + Aspirin + Clopidogrel + then 0.5 mg/kg (maximum 35 mg) over the Anticoagulant next 60 minutes (IV infusion)  For 6-12 hours after symptoms onset use 3 hours (Enoxaparin) dose regimen. (See BNF). Max total dose of 100mg administered over 90 minutes.

 When primary percutaneous coronary intervention cannot be provided within 120 minutes of ECG diagnosis, patients with an ST- segment-elevation should receive immediate (prehospital or admission) thrombolytic therapy.

 Exclude contraindications for thrombolytics use. o Examples (not comprehensive) : Previous intracranial haemorrhage or of unknown origin at anytime, Ischaemic stroke in the last 6 months, recent (within 1 month) major trauma / surgery / head injury, GI bleeding, aortic dissection.

 Antiplatelets - co-administer soluble Aspirin 300mg + Clopidogrel 300mg once. Then continue 75mg once daily for both. o Clopidogrel is the preferred ADP inhibitor of choice as co-adjuvant and after . You may consider switching to / 48hours after thrombolysis in patients who underwent PCI.

- recommended until revascularisation (if preformed) or for the duration of hospital stay (up to 8 days) o Enoxaparin IV followed by S.C. as follows (maximum dose applies for the first two S.C. doses only):

. Aged <75 - 30mg IV bolus, followed 15min later by 1mg/kg twice a day. The first two S.C. doses should not exceed 100mg per injection.

. Aged ≥75 - no IV bolus. First S.C. dose of 0.75mg/ kg with a maximum 75mg per injection for the first two S.C. doses.

. If eGFR < 30 mL/min/1.73m2 the S.C. dose should be given once daily, regardless of age.

o If not suitable, use UFH. 60 units/kg bolus (maximum 4000 units) followed by an intravenous infusion of 12 units/kg per hour (maximum 1000 units per hour) adjusted to target aPTT of 50 to 70 seconds (or 1.5 to 2.0 times that of control).

Abbreviations: ADP = adenosine diphosphate. aPTT = activated partial thromboplastin time. eGFR = estimated glomerular filtration rate. IV = intravenous. IU = international units. PCI = Percutaneous Coronary Intervention S.C. = subcutaneous. UFH = unfractionated .

Sources: BNF Jan 2020, UpToDate 2020, SPCs online accessed March 2020, SIGN. 2016. Acute coronary syndrome (148). ESC. 2017. STEMI Guidelines. NHS England & NHS Improvement. 2020. Clinical guide for the management of cardiology patients during the coronavirus pandemic.

Summarised by: Dr Rani Khatib, Consultant Cardiology Pharmacist, Leeds Teaching Hospitals NHS Trust. April 2020. Checked by: Prof Stephen Wheatcroft, Consultant Cardiologist, Leeds Teaching Hospitals NHS Trust. April 2020.