Medical Management with Thrombolysis

Numerous studies have been performed and enough evidence accumulated showing an unequivocal benefit, in terms of mortality and morbidity, in regards to thrombolytic treatment of patients presenting with AMI. As discussed above, the FTT collaborative group found patients who presented within a 'therapeutic window' (less than 1 h) of symptom onset and found to have either LBBB or STEMI benefited most from thrombolytic therapy, most benefit being seen in those treated soonest after onset of symptoms. Patients presenting after 12 h should not receive fibrinolytics, unless there is evidence of ongoing ischemia, as no significant benefit has been shown. Unless clearly contraindicated (see Table 2), patients with infarction, particularly, STEMI (ST elevation greater than 0.1 mV in 2 contiguous leads) or new LBBB, should receive prompt treatment with fibrinolytic therapy and aspirin without delay. Patients with LBBB or anterior ST elevation are at greater inherent risk from MI and achieve greater benefit with fibrinolytic therapy. If possible, fibrinolysis should be started within 90 min of the patient calling for medical treatment ('call-to-needle' time) or within 30 min of arrival at the hospital ('door-to-needle' time).74 As per the American College of Cardiology (ACC) guidelines, attainment of additional ECG leads (right sided and/or posterior) or an echocardiogram may help clarify the location and extent of infarction and anticipated risk of complications, but it is important that acquisition of such ancillary information does not interfere with the strategy of providing timely reperfusion in patients with STEMI.

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