Thrombolytic therapy- highly effective assistance for ischemic stroke, which allows you to restore blood flow in the affected vessel and prevent irreversible changes in brain tissue.
Currently, for thrombolysis in ischemic stroke, preference is given to alteplase (Actilyse) - the drug has undergone clinical trials and has proven itself well in randomized trials. How it works: Recombinant tissue plasminogen activator (Actilyse) directly activates the conversion of plasminogen to plasmin. After intravenous administration, alteplase remains relatively inactive in the circulation. It is activated by binding to fibrin, which causes the conversion of plasminogen to plasmin and leads to the dissolution of the fibrin clot (the main component of the blood clot).
Thrombolysis is performed in patients with stroke in the first 3-4.5 hours from the onset of neurological symptoms. Only in a hospital, after determining the criteria for indications/contraindications and conducting a number of necessary studies.
Today, VTT is a standard method of treating patients in the most acute period of IS in the absence of contraindications. The method is applicable in most neurological hospitals and does not require lengthy or complex preparation. To make a decision on starting VTT, a relatively small amount of clinical, instrumental and laboratory studies is required. At the same time, due to a significant number of contraindications, only about 5-10% of patients with acute ischemic cerebrovascular accident (ACVA) can potentially be selected for this type of treatment, and a narrow “therapeutic window” (4.5 hours) presents high requirements for the speed of transportation and examination of the patient. The effectiveness of the drug of choice - recombinant tissue plasminogen activator - depends on the level of serum plasminogen, the volume and duration of the thrombus.
However, there are contraindications:
- Bleeding of various localizations. During TLT, all blood clots are dissolved in the vessels, and those that form as a result of bleeding are not excluded.
- Possible aortic dissection.
- Arterial hypertension.
- Intracranial tumors.
- Hemorrhagic stroke (hemorrhage caused by rupture of the walls of cerebral vessels).
- Liver diseases.
- Pregnancy.
- Brain surgeries.
Thrombolytic therapy for ischemic stroke should be carried out in an intensive care unit.
According to international recommendations, the time from the patient’s admission to the hospital to the start of thrombolytic therapy should not exceed 60 minutes (door-to-needle time). During this time, it is necessary to determine the indications and exclude contraindications to thrombolytic therapy.
Necessary:
1. Examination by a neurologist and collection of anamnesis, assessment of vital functions and neurological status. An examination using the NIHSS stroke scale is necessary. Thrombolytic therapy is indicated for NIHSS scores between 5 and 25.
2. Immediately perform a computed tomography scan of the brain.
3. Changes in blood pressure levels in both arms.
4. Installation of a cubital peripheral venous catheter.
5. Measuring serum glucose levels.
6. Taking blood and performing the following laboratory tests:
a) platelet count;
b) APTT;
c) INR.
7. Provide at least 24 hours of monitoring:
1) blood pressure level;
2) heart rate;
3) frequency of respiratory movements;
4) body temperature;
5) oxygen saturation.
Thrombolysis can be:
- Systemic;
- Local.
Methods of thrombolytic therapy
The first method is advantageous in that the medicine can be injected into a vein without having any idea where the blood clot is hidden. With the bloodstream, the drug is carried throughout the entire blood circulation, where on its way it encounters an obstacle in the form of a blood clot and dissolves it. But systemic thrombolysis has a significant drawback: an increased dose of medication is required, and this is an additional burden on the entire circulatory system.
INDICATIONS FOR THROMBOLYSIS IN ACUTE ISCHEMIC STROKE:
Severe neurological deficit associated with acute ischemic stroke and, apparently, caused by occlusion of a large artery (basilar, vertebral, internal carotid): in the form of disorder of movements, speech, facial paresis, disorder of the level of consciousness. Using special scales (NIHS scale), a neurologist assesses the level of neurological deficit.
. absence of hemorrhage according to computed tomography
. development time from the beginning of the clinic up to 3 hours (up to 6 hours with selective thrombolysis, up to 12 hours with a heart attack in the basilar artery basin)
THROMBOLYSIS IS CONTRAINDICATE:
ABSOLUTE CONTRAINDICATIONS:
1) minor and rapidly regressing neurological deficit
2) hemorrhage, clearly visible extensive acute cerebral infarction or other CT data that are contraindications (tumor, abscess, etc.)
3) convincing evidence of the presence of a vascular malformation or tumor of the central nervous system in the patient
4) bacterial endocarditis
RELATIVE CONTRAINDICATIONS:
1) severe injury or stroke within the last 3 months
2) history of intracranial bleeding or suspected diagnosis of subarachnoid hemorrhage
3) major surgery in the last 2 weeks
4) minor surgery within the last 14 days, including liver or kidney biopsy, thoracentesis and lumbar puncture
5) arterial puncture within the last 2 weeks
6) pregnancy (ten days after birth) and breastfeeding
7) acute gastrointestinal bleeding, urological or pulmonary bleeding in the last three weeks
8) history of hemorrhagic diathesis (including renal and liver failure)
9) peritoneal or hemodialysis
10) changes in coagulogram (PTT more than 40 seconds, prothrombin time more than 15 (INR more than 1.7), platelets less than 100,000)
11) convulsive seizure as the onset of a stroke (a careful differential diagnosis is required)
12) changes in blood glucose levels (hypo or hyperglycemia)
ADMINISTRATION:
Non-selective thrombolysis is most often performed. To carry it out, after a minimal examination of the patient (examination by a neurologist, computed tomography to exclude hemorrhage), a general blood test with platelet levels, blood biochemistry (glucose level), coagulogram, if possible), 100 mg of the drug akilyse is administered intravenously: 10 mg is administered as a bolus, the rest 90 mg - intravenous drip on physical therapy. solution 0.9% 400.0 for 1 hour.
COMPLICATIONS OF THROMBOLYSIS:
The main complications are the risk of bleeding (nasal, gastrointestinal, renal) and the risk of transformation of the ischemic focus into hemorrhage in the brain.
Thrombolytic therapy makes it possible to witness a truly dramatic improvement in the patient’s condition, when severe neurological disorders literally disappear “on the needle”, and he not only survives, but also recovers, which was previously almost impossible.
Local thrombolysis: During local thrombolysis, the drug is injected directly into the location of the thrombus. The drug is supplied through a catheter, which is why the method is called catheter thrombolysis. However, this method is more difficult to implement than the first and is associated with a certain danger. During the procedure, the doctor monitors the movement of the catheter using x-rays. The advantage of this method is its low invasiveness. It is used even if the patient has a large number of chronic diseases.
The process of destruction (dissolution of a blood clot) under the influence of drugs is called. The procedure for administering these drugs itself received the same name.
What does thrombolysis provide?
This technology, the first information about which appeared in 1981, has turned the old ideas about help upside down.
With its use, mortality, provided therapy was provided within the first 60 minutes from the onset of severe symptoms, decreased by 51%.
Even the use of thrombolysis at a later stage (from 6 to 12 hours) reduces mortality by 18%.
Therefore, it is so important to carry out this manipulation in a timely manner when providing emergency care to a patient.
- restores artery patency;
- limits the spread of the necrosis zone;
- reduces the number of complications in the form of aneurysms;
- during myocardial infarction, it increases the electrical stability of the myocardium and also supports the pumping function of the left ventricle.
Carrying out thrombolysis in an ambulance
Indications for testing
Thrombolysis must be used in all cases of uncontrolled, these are:
Thrombolysis is carried out by a team of a doctor and a paramedic. Performing the procedure by a single health care worker seems questionable and unjustified.
Contraindications
Despite the urgency of the situation, specialists providing assistance must clarify the existence of the following circumstances:
- Hemorrhagic stroke preceded thrombosis within 6 months.
- Stomach ulcer with bleeding.
- Any internal bleeding in the last two weeks.
- A history of traumatic brain injury in the period 2 weeks before the attack.
- Suspicion of pericarditis.
- Threat of aortic aneurysm.
- Major surgery no more than three months ago.
- Allergy to a drug that is planned to be used for thrombolysis.
- Pregnancy.
- Recent birth.
It is necessary to take into account other circumstances that complicate thrombolysis:
- Liver failure.
- Kidney failure.
- Diabetes.
- Neoplasms.
- Acute phase of infectious diseases.
- Use of anticoagulants in the last six months.
First ambulance actions
After diagnostics and ECG readings, it is necessary to administer anesthesia (severe pain can cause confusion), and administer a vasodilator intravenously.
Before intravenous use of a thrombolytic drug, the paramedic is required to obtain voluntary written informed consent from the patient, which will be stored along with the protocol for calling the ambulance team.
If cardiogenic shock has developed and the patient cannot confirm consent in writing, the doctor or paramedic informs the head of the emergency medical service about this, obtaining his consent to thrombolysis.
When transporting to a specialized clinic, where stenting or bypass surgery will be possible, the medical team constantly monitors the patient’s condition:
- takes an ECG;
- measures blood pressure and pulse;
- measures blood saturation level;
- If necessary, performs cardiopulmonary resuscitation.
Drugs intended for thrombolysis
Thrombolysis for myocardial infarction at the prehospital stage is carried out in a peripheral vein using proven drugs, each of which has pros and cons:
- Streptokinase. Converts plasminogen to plasmin, and this leads to systemic fibrinolysis. A side effect of its use is bleeding. The main disadvantage is allergenicity.
- Urokinase. The survival rate with this drug is 15% greater than that of streptokinase. It is used only simultaneously with intravenous heparin.
- Anistreplase. It is used by jet injection without heparin.
- Alteplase. A week of pre-therapy with heparin is required, so its use is inconvenient in the prehospital stage. Used in patients who have previously received streptokinase.
- Actilyse., quickly reducing its size without affecting other components. Does not destroy fibrinogen, thereby reducing the risk of general bleeding. May cause slight hemorrhage at the injection site, which is not a reason to discontinue use.
Overdose should not be allowed (at doses above 100 mg) to avoid side effects such as:
- reducing the concentration of coagulation factors;
- bleeding in various systems;
- nausea and vomiting;
- lowering blood pressure;
- temperature rise;
- headache;
- allergic reaction.
If the patient's body weight is less than 65 kg, the total dose of the drug cannot exceed 1.5 mg/kg.
Enter:
- 15 mg is administered as a bolus (quickly, in 1-2 seconds),
- then within half an hour - 0.75 mg/kg;
- and over the next hour - 0.5 mg/kg.
Metalise. The drug is incompatible with glucose. It is excreted in bile, so it can be used for renal failure. Has a large percentage reduction in mortality even with late use. The dose of the drug is selected according to the patient’s weight. The drug is administered as a bolus (intravenously, once over 5-10 seconds), which is its advantage over most other thrombolytics that require drip administration.
All these drugs have one common significant disadvantage: their cost is calculated in tens of thousands of rubles.
Elderly patients have an increased risk of intracranial hemorrhage.
Thrombolysis (TLT, thrombolytic therapy) – from the Latin Thrombolysis, a type of drug therapy that is aimed at restoring normal blood circulation by affecting the blood clot until it is completely dissolved in the vessel.
Drugs that dissolve blood clots help save lives in a variety of vascular pathologies, including thrombosis of the pulmonary artery (PE), deep veins of the legs, ischemic stroke and blockage of coronary arteries, leading to the death of heart tissue.
Why is thrombolysis used?
As the body ages, blood vessels also age, causing them to lose their former elasticity. In the vascular tissues themselves, metabolic processes are disrupted, and the blood clotting system also suffers.
Subsequently, blood clots called thrombi form, which can interfere with blood flow or completely block the vessel.
This condition is very dangerous, as gradual tissue death occurs as a result of oxygen starvation. The most dangerous is damage to the vessels supplying the brain and heart, which leads to stroke and heart attack, respectively.
In such a situation, only the provision of effective and timely assistance both at the prehospital stage and in the hospital can save the life of the affected person. Thrombolytic therapy is a very important and effective treatment method.
Thrombolysis therapy is the administration of special medications that affect the rapid dissolution of blood clots. What price?
This procedure is not cheap. But they will most effectively help save lives. Since the use of thrombolysis is, in most cases, an emergency measure, the cost of injections is included in the insurance.
The approximate cost of the thrombolytic Actilyse in Ukraine (Kyiv) is 14,500 hryvnia. The pricing policy will vary depending on the type of drug and its manufacturer.
In Russia, this drug costs about 27,000 rubles. There are analogues whose prices differ. More details should be obtained directly from the place of purchase.
What methods exist for breaking blood clots?
This treatment method is classified according to two methods of therapy:
- Selective method– a drug that dissolves a blood clot is injected directly into the pool of the affected vessel. This method of therapy can be used within six hours after blockage of the vessel;
- Non-selective method– thrombus-dissolving drugs are administered intravenously into the affected artery within three hours after the blood circulation has slowed down.
Also, there are two types of TLH depending on the localization of therapy:
- System– used when the site of thrombosis is not determined. It is carried out by introducing an enzyme into a vein, which is distributed immediately throughout the entire blood circulation. The technical application of the method is very simple, but will require a large amount of medicine. The disadvantage of the systemic method is the high risk of hemorrhage;
- Local– this method of treatment is more difficult to implement, since thrombolytics, which dissolve the blood clot, are injected directly into the place where the vessel is blocked. Also, during the method, a contrast agent is injected and catheter angiography is performed to monitor the dissolution process.
The doctor monitors changes as the thrombolytic drug dissolves the clot.
But with a local treatment method, the risk of progression of massive hemorrhages is significantly reduced. Indications for thrombolysis
The main indications for thrombolysis are pathologies of the heart and blood vessels (myocardial infarction, occlusion of the deep veins of the legs, pulmonary embolism, stroke, damage to the peripheral arteries or shunt, as well as ischemic stroke).
The prehospital stage, when the location of the thrombus has not yet been precisely determined, is characterized by its indications for the use of thrombolysis:
- Transporting the victim to the hospital for more than thirty minutes;
- Thrombolytic treatment was forced to be postponed for more than sixty minutes.
The main indications for thrombolysis after hospitalization are:
- Complete block of the left bundle branch, with the formation of a blood clot less than twelve hours ago. Unstable blood circulation with a preserved rate of ST elevation on the electrocardiogram (ECG);
- A decrease in ST in leads V1-V2 with an increase in the amplitude of the R-waves, which directly indicates tissue death in the heart, in the area of the posterior wall of the left ventricle;
- The increase in ST is above 0.1 and 0.2 in at least two leads of the electrocardiogram.
Thrombus lysis is most effective on fresh blood clots that blocked the vessel less than two hours ago. It is during this period that thrombolysis is recommended, which will have maximum effectiveness.
Drugs that affect the dissolution of blood clots significantly improve prognosis when administered within the first six hours from the moment the first symptoms appear. Also, the survival rate increases when thrombolysis is performed within twenty-four hours.
Contraindications to thrombolysis
The main contraindications for thrombolytic therapy are the high risks of hemorrhages, which can be both traumatic and pathological in the six-month period preceding thrombolysis.
This is explained by the fact that during therapy to dissolve blood clots, blood clots in the body are liquefied, which makes the blood more liquid.
Blood clot dilution therapy is not performed if the following factors are present:
What is special about thrombosis of the heart vessels?
It is prohibited to use drugs to dissolve blood clots on your own, as complications may progress. This therapy is performed only by qualified specialists based on examinations of the body.
The examination consists of ultrasound examinations, Doppler ultrasound and duplex scanning, as well as angiography. All these studies help to clearly determine the location of the blood clot, after which medications are injected into the blocked vessel to dissolve the blood clot.
Blockage of heart vessels is one of the most dangerous types of thrombosis in the body.
With partial or complete closure of the vessels that feed the heart, the death of cardiac muscle tissue progresses.
With such a lesion, it is very important to apply effective treatment in a timely manner, since there is a direct and very serious threat to life.
The victim must be urgently taken to the hospital by ambulance, since during transportation, in critical conditions, doctors can perform thrombolysis right on the way to the hospital.
What are the characteristics of thrombolysis during brain tissue death?
Sudden interruptions in the supply of blood to the cavities of the brain, provoking serious disorders in the area of neuralgia, are called a stroke.
According to statistics, in the CIS, up to fifty percent of patients die, and many of them - in the first thirty days, and most survivors remain disabled for the rest of their lives.
This is due to the fact that the thrombolysis procedure is expensive, and not every citizen of the post-Soviet space can afford it. Also affected by the lack of insurance, which includes the possible use of thrombolytics.
In countries where the experience of using thrombolysis has been around for many years, statistics indicate a mortality rate of twenty percent.
And the majority of surviving patients experience complete restoration of the functionality of the nervous system.
So thrombolism is the most effective method of treating ischemic stroke.
The procedure is quite simple and effective, but has its contraindications:
- Hemorrhages;
- Increased pressure in the cranial cavity;
- Pregnancy;
- Brain surgery;
- Liver pathologies;
- Tumor formations localized inside the skull;
- Bleeding caused by deformation of the walls of blood vessels located in the brain.
Medicine does not differentiate patients by age category when performing thrombolysis. This therapy can be carried out at absolutely any age.
The first signs of a stroke are numbness of an arm or leg on one side, speech impairment and facial distortion. It is important to provide assistance in the first six hours with the appearance of the first signs, this will help save the patient’s life. If you delay, the risk of death increases every minute.
That is why it is necessary to know how to identify the first signs of a stroke, what are the ways to identify the pathological condition at home, since the affected person has very little time. What drugs are used for thrombolysis therapy?
The main drugs used for thrombolysis are the following:
- Alteplase. Refers to thrombolytics, but is expensive. With timely use of this drug, there is a higher chance of survival than with Streptokinase. For a week after using this drug, it is necessary to carry out Heparin therapy. The only negative effect is the risk of brain bleeding;
- . It is the cheapest drug for thrombolysis. Its obvious disadvantage is its frequent incompatibility with the human body, which leads to allergic reactions. Also, the drug is administered over an hour. When this drug is administered, multiple hemorrhagic side effects progress. Streptokinase has provided the impetus for the pharmacological development of more modern thrombolysis drugs;
- Anistreplase. It is an expensive drug that can be administered as a bolus, which greatly facilitates its administration at the pre-hospitalization stage. The use of Heparin is not required;
- Urokinase. The pricing policy is average between the above drugs, but its advantages over the cheapest drug have not yet been proven. Requires administration of Heparin. Fifteen percent more survival is achieved than with Streptokinase.
Complications
The main burdens are:
- Decline in blood pressure;
- Hemorrhages, from small to life-threatening;
- Fever;
- Rashes – observed in a third of affected patients;
- Chills;
- Allergies; Prevention of thrombosis
- Proper nutrition;
- Maintaining water balance (at least 1.5 liters of clean water per day);
- Correct daily routine with proper rest and sleep;
- Sports activities (dancing, swimming, athletics, physical education, etc.), as well as walking for at least one hour a day;
- Timely treatment of diseases;
- Regular scheduled examinations will help to diagnose possible pathologies in advance.
To minimize the risk of blood clots, you should adhere to the following steps:
Expert forecast
Predictions are made in each individual case of thrombosis. It all depends on the location of the blocked vessel, the speed and effectiveness of the assistance provided. With timely administration of thrombolytics (no more than three hours), the prognosis is more favorable.
If the drugs are administered within six hours, the prognosis is favorable, but there is a risk of not being able to save the person. Anything that exceeds this time, in most cases, ends in tissue death, even death.
The first use of thrombolytic drugs dates back to 1949. After 10 years, it was possible to obtain data on the positive reaction of the human body to the use of drugs. Initially, thrombolytic therapy was used, but gradually the scope of use expanded significantly. Although the treatment results were successful, medicine was in no hurry to actively use thrombolytics. Worldwide recognition of thrombolytic therapy (TLT) came only in 1989.
Thrombolytic therapy helps eliminate blood clots.When comparing anticoagulants and antiplatelet drugs, thrombolytics lack only a preventive effect. Analogs are aimed at preventing the formation of new blood clots in the circulatory system. And TLT allows you to dissolve and eliminate the fibrin clots (thrombi) that have appeared. This allows you to restore blood flow in the area of ischemia of the damaged organ and restore its functions.
Indications
There are certain indications for thrombolytic therapy, which the attending physician considers when choosing treatment tactics for the patient. Each case is considered individually, therefore it is extremely important to first undergo a set of diagnostic measures. This will make it possible to understand whether thrombolytics can be used in treatment in this situation, or whether an alternative to thrombolytic therapy should be sought. In modern treatment, TLT is widely used in the fight against diseases that are accompanied by the presence of fibrin blood clots.
Thrombi are divided into venous and arterial, and are also caused by pulmonary, paradoxical or systemic thromboembolism. Recently, thrombolytic drugs have been actively prescribed to patients who have been diagnosed with pulmonary embolism (PE); these drugs demonstrate fairly high effectiveness.
TLT or thrombolysis is important to use for:
- myocardial infarction;
- TELA;
- peripheral and central arterial thrombosis;
- thrombosis of the veins of the liver, kidneys and others (exceptions are);
- strokes;
- thrombosis of the central retinal vein;
- clogging of implanted valves;
- clot formations in aorto-coronary and other bypass grafts;
- thrombosis of peripheral arteries.
Medical practice clearly shows that thrombolytic therapy for ischemic stroke, heart attacks and various types of thrombosis is highly effective. The indicated indications for thrombolysis must be compared with the contraindications present in each individual patient. Indications and contraindications may contradict each other, that is, there are reasons for TLT, but other health problems do not allow this option of drug therapy. Therefore, contraindications to thrombolytic therapy should be considered separately. To assess the degree of effectiveness of thrombolytic drugs, patients are referred for comprehensive diagnostics. The most informative examination methods are:
- electrocardiogram (ECG);
- angiography.
After assessing the condition, the attending physician makes the final decision on the possibility or impossibility of thrombolytic therapy.
Contraindications
Thrombolytic drugs can cause unpleasant and potentially dangerous side effects. One of the main and most undesirable symptoms is bleeding. Due to bleeding, the course of the disease can worsen and negatively affect the general condition of the body. Therefore, specialists carefully check each patient for contraindications and possible threats to his health when taking thrombolytics. All considered contraindications are divided into two groups:
- absolute;
- relative.
In case of absolute contraindications, the use of drugs is strictly prohibited., and in the case of relative threats, appointments are approached individually. Practice clearly shows that a number of relative contraindications still make it possible to carry out thrombolytic therapy for pulmonary embolism, heart attacks, strokes, various types of thrombosis, etc.
Relative
Let's start with the relative restrictions on the use of TLT for stroke, myocardial infarction, pulmonary embolism and other diseases that are accompanied by fibrin thrombi. They are relevant for:
- infective endocarditis;
- severe pathologies associated with the liver and kidneys;
- carrying a child (regardless of the duration of pregnancy);
- severe, when the pressure rises to 180/110 and above;
- acute pericarditis;
- diseases that cause bleeding;
- pathologies of cerebral vessels (human brain);
- diabetic hemorrhagic retinopathy;
- undergone surgical operations or injuries that are associated with damage to the cerebral and spinal cord;
- deep vein thrombosis in the legs;
- bleeding coming from the genitourinary or digestive systems;
- bone fractures;
- serious burns that affect most of the body;
- recently performed thrombolytic therapy (4–9 months ago) with the need to use similar thrombolytics.
If the patient has already undergone drug therapy using Streptokinase or APSAC tablets, then over the next 4 to 9 months doctors usually do not recommend taking a second course of the same medications. But when analogues are prescribed, therapy earlier than the specified period is allowed.
Absolute contraindications
The previous group discussed contraindications that can be challenged and, in some situations, violated. Absolute limits are now considered. That is, in their case, thrombolytic therapy is strictly prohibited. In the opposite situation, this can lead to extremely serious and dangerous consequences. To avoid unwanted complications, doctors are required to conduct a thorough examination of the patient's health status in order to identify prerequisites for absolute contraindications to thrombolytic drug therapy.
Treatment with thrombolytics should not be carried out if:
All this indicates that the patient is prohibited from using thrombolytic therapy to treat the resulting blood clots. We have to look for alternative solutions or wait for the moment when absolute contraindications become relative or disappear completely. To do this, you have to begin active treatment of the underlying disease, wait until the end of the recovery period after surgery, etc.
It will not be possible to cope with allergic reactions and individual intolerance to thrombolytics.
Thrombolytics used
A large list of drugs is widely used in thrombolytic therapy. But they all operate according to only two principles:
- some deliver already activated plasmin to the patient’s body;
- other drugs activate plasminogen, which accelerates the formation of plasmin derived from it.
Two mechanisms make it possible to classify all drugs of the thrombolytic group into 3 categories.
- Direct. These are drugs of plasma origin that have a proteolytic direct effect and a specific effect on fibrins.
- Indirect. These are so-called drug-agents that activate the formation of plasmin by acting on plasminogens.
- Combined. Such thrombolytic medications can have a double effect, that is, they combine the functions and properties of the two previous groups of drugs.
You should also consider the drugs themselves, which have gained popularity and are widely used in modern medicine to combat the consequences of fibrin blood clots. Let's talk about several thrombolytics that are most relevant for treatment in our clinics.
"Fibrinolysin"
It contains plasminogen, which was isolated from human blood plasma and activated with trypsin. The thrombolytic drug is a direct-acting drug, but is not sufficiently effective. It acts slowly on febrile arterial blood clots that have formed. Although the drug is not the best, it continues to be actively used in Russia, Ukraine, and the CIS countries. This is largely due to the impossibility of using alternative thrombolytics, which are more effective, but also equally expensive.
When the drug is injected into the blood of a sick patient, a special streptokinase-plasminogen complex is formed in it, ensuring the creation of the required amount of plasmin. To obtain such an indirect thrombolytic drug, specialists created a non-enzymatic protein (peptide), which is part of group C streptococcus. This is a direct plasminogen activator.
It should be taken into account that taking the drug may provoke the human body to produce antibodies to the active ingredients. This reaction is due to the fact that the medicine is based on cultures of streptococcus, to which the defense system produces antibodies, perceiving the thrombolytic as a threat.
The immune reaction usually lasts about a month and stops after six months. This explains the fact that it is not recommended to take Streptokinase again earlier than 4 to 9 months after the first use. Also, you cannot use APSAC during this period. In order to prevent such a protective reaction, which does not allow the thrombolytic drug to fully perform its tasks, it is recommended to take a short course of corticosteroids or an antihistamine before taking a thrombolytic drug.
"Urokinase"
This thrombolytic is a complete enzyme. It is obtained from cultures produced by kidney cells. The entry of such a substance into the body of a sick patient leads to the activation of plasminogen and ensures its conversion into plasmin.
Compared to Streptokinase, Urokinase does not have the same effect when the body turns on the defense system and produces antibodies. Allergic reactions are extremely rare.
"Prourokinase"
This is a fairly effective plasminogen activator. Don’t be too alarmed, but they are creating a drug based on DNA-recombined kidney cells obtained from an embryo. The drug has two forms of release:
- glycosylated;
- non-glycolysed.
In terms of efficiency, they are not very different from each other. The only significant difference for patients is that the glycolyzed form is able to have a faster effect after administration.
"APSAK"
With the help of the acetylated plasminogen-streptokinase complex, it is possible to effectively resist fibrin blood clots. A special feature of the drug is its high speed of influence on formations in blood vessels.
Therefore, APSAC has found wide application in thrombolytic therapy. This is not the entire list of available medications intended for thrombolytic therapy. This method of treatment allows you to quickly and effectively deal with the resulting blood clots that have formed a blood clot and pose a potential threat to human health or life. It is strictly forbidden to purchase and use thrombolytics yourself. In this case, self-medication can have serious consequences. Therefore, first visit the clinic, undergo a comprehensive examination, check your condition for contraindications, after which, as prescribed by your doctor, you will undergo a full-fledged course of medication.
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The indication for thrombolysis is myocardial infarction with pathological Q waves and the ability to administer a thrombolytic in a time frame that allows hope for an improved prognosis.
Chest pain characteristic of myocardial infarction for more than 30 minutes ECG signs of myocardial infarction with pathological Q waves:
Thrombolytics have been shown to improve prognosis if they are administered within the first 6 hours after the onset of chest pain. A number of studies, however, have shown that survival increases when thrombolytics are administered at a later date - up to 24 hours from the moment of coronary artery occlusion. Therefore, in certain cases, for example, with wave-like pain syndrome, you can resort to thrombolysis within 24 hours after the onset of the first symptoms.
So, indications for thrombolysis:
- ST segment elevation of more than 1 mm (0.1 mV) in two or more adjacent leads (for example, II, III, aVF)
- ST segment depression and increased amplitude of R waves in leads V1-V2 (signs of infarction of the posterior wall of the left ventricle)
- Newly diagnosed left bundle branch block Timing of thrombolytic administration:
- Less than 6 hours after pain onset: maximum effectiveness
- More than 12 hours: less effective, but if chest pain persists, thrombolysis is indicated
Contraindications to thrombolysis
The main contraindication to thrombolysis is the increased risk of bleeding. Patients who have previously received streptokinase or anistreplase should not be reintroduced to either drug due to the risk of allergic reactions.
Old age is not a contraindication to thrombolysis: although in most cases it is carried out before the age of 75, thrombolytics should be used at an older age, if there are no contraindications and severe concomitant diseases.
So, contraindications to thrombolysis:
- Major surgery or injury in the previous 6 weeks
- Bleeding from the gastrointestinal tract or urinary tract in the previous 6 months
- Blood clotting disorders
- Suspicion of acute pericarditis, dissecting aortic aneurysm
- Resuscitation lasting more than 10 minutes
- History of intracranial tumors or brain surgery
- Acute cerebrovascular accident in the previous 6 months
- Severe arterial hypertension (BP > 200/120 mmHg)
- Pregnancy
In specialized centers, an alternative to thrombolysis is primary balloon coronary angioplasty (often with stent placement). It has the greatest advantage in cases of contraindications to thrombolytics, cardiogenic shock and extensive anterior myocardial infarction.
