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Old 06-03-2014
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Default tPA Contraindications compare between ACS/Stroke

So, I've been trying to get along this annoying issue of the contraindications for thrombolytics. My issue is simple : Why are there different CI if you are using it in the heart (i.e ACS-STEMI), and different CI when you are using in Brain (i.e ischemic stroke). Its the same god damn vessel (i.e a peripheral vein) you are going to inject in, and the Contraindications should be the same.

To elaborate, MTB2 lists the following CI for thrombolytics under ACS:
1. Major bleeding in bowel(Melena) or Brain(any type of CNS bleeding)
2. Recent surgery within last 2 week
3. >180/110
4. Ischemic stroke within 6 month.

MTB3 lists the following CI for thrombolytics under Stroke:
1. Hx of Hemorrhagic stroke
2. Presence of intracranial neoplasm/mass
3. Active bleeding/surgery within 6 weeks
4. Presence of bleeding disorder
5. CPR within 3 weeks that was traumatic (chest compression)
6. Suspicion of Aortic dissection
7. Stroke within 1 year
8. Cerebral trauma or brain surgery within 6 months

Furthermore, the mnemonic SHIPBLAST for tPA CI in CVA lists the following:
S= Stroke in the last 3 months
H= Head injury in the last 3 months
I= Intracranial hemorrhage
P= PT > 15 seconds
B= BP > 185/110
L= Lumbar Puncture in last 7 days
A= Anticoagulants use / Arterial puncture in last 7 days
S= Surgery within last 14 days
T= Thrombocytopenia < 100,000/mm

Three lists (few items overlap, but you can see some are different)!! And so much to mug up! I am just trying to find a common ground, and the common elements, so that its easier to recall.

I really don't understand the logic to have different CI for STEMI or Ischemic stroke. Regardless of the location, tPA will go everyone, and the CI should be the same....at least theoretically.

Also, Emed has its own different lists. I'll post them in the next post.

What do you guys think? Any input?
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  #2  
Old 06-03-2014
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Default

Here is from EMED:

ACS:

Absolute:
  1. Prior intracranial hemorrhage (ICH)
  2. Known structural cerebral vascular lesion
  3. Known malignant intracranial neoplasm
  4. Ischemic stroke within 3 months
  5. Suspected aortic dissection
  6. Active bleeding or bleeding diathesis (excluding menses)
  7. Significant closed head trauma or facial trauma within 3 months
  8. Intracranial or intraspinal surgery within 2 months
  9. Severe uncontrolled hypertension (unresponsive to emergency therapy)
  10. For streptokinase, prior treatment within the previous 6 months
Relative contraindications for fibrinolytic use in STEMI include the following:
  1. History of chronic, severe, poorly controlled hypertension
  2. Significant hypertension on presentation (systolic blood pressure > 180 mm Hg or diastolic blood pressure > 110 mm Hg
  3. Traumatic or prolonged (> 10 minutes) cardiopulmonary resuscitation (CPR) or major surgery less than 3 weeks previously
  4. History of prior ischemic stroke not within the last 3 months
  5. Dementia
  6. Recent (within 2-4 weeks) internal bleeding
  7. Noncompressible vascular punctures
  8. Pregnancy
  9. Active peptic ulcer
  10. 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

CVA/Stroke
Absolute:
  1. History or evidence of intracranial hemorrhage
  2. Clinical presentation suggestive of subarachnoid hemorrhage
  3. Known arteriovenous malformation
  4. Systolic blood pressure exceeding 185 mm Hg or diastolic blood pressure exceeding 110 mm Hg despite repeated measurements and treatment
  5. Seizure with postictal residual neurologic impairment
  6. Platelet count below 100,000/ÁL
  7. Prothrombin time (PT) above 15 or INR above 1.7
  8. Active internal bleeding or acute trauma (fracture)
  9. Head trauma or stroke in the previous 3 months
  10. Arterial puncture at a noncompressible site within 1 week

Relative contraindications for alteplase therapy for AIS include the following:
  1. Pregnancy
  2. Rapidly improving stroke symptoms
  3. Myocardial infarction (MI) in the previous 3 months
  4. Glucose level lower than 50 mg/dL or higher than 400 m

I wish there was an easier way to gulp these freaking lists!
I'll try to get the common elements, and make a final list I guess.
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