Long Brit, Brady William J, Gottlieb Michael
Department of Emergency Medicine, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
Am J Emerg Med. 2025 Mar;89:85-94. doi: 10.1016/j.ajem.2024.12.007. Epub 2024 Dec 11.
Several life-threatening conditions associated with thrombosis include acute ischemic stroke (AIS), acute myocardial infarction (AMI), and acute pulmonary embolism (PE). Fibrinolytics are among the treatment algorithms for these conditions.
This narrative review provides emergency clinicians with an overview of fibrinolytics for AIS, AMI, and PE in the emergency department (ED) setting.
Pathologic thrombosis can result in vascular occlusion and embolism, ultimately leading to end-organ injury. Fibrinolytics are medications utilized to lyse a blood clot, improving vascular flow. One of the first agents utilized was streptokinase, though this is not as often used with the availability of fibrin-specific agents including alteplase (tPA), tenecteplase (TNK), and reteplase (rPA). These agents are integral components in the management of several conditions, including AIS, AMI, and PE. Patients with AIS who present within 3-4.5 h of measurable neurologic deficit with no evidence of intracerebral hemorrhage (ICH) or other contraindications may be eligible to receive tPA or TNK. In the absence of percutaneous coronary intervention (PCI), fibrinolytics should be considered in patients with AMI presenting with chest pain for at least 30 min but less than 12 h, though it may be considered up to 24 h. Unlike in AIS and PE, anticoagulation and antiplatelet medications should be administered in those with AMI receiving fibrinolytics. Following fibrinolytics, PCI is typically necessary. Fibrinolytics are recommended in patients with high-risk PE (hemodynamic instability), as they reduce the risk of mortality. The most significant complication following fibrinolytic administration includes major bleeding such as ICH, which occurs most frequently in those with AIS compared to AMI and PE. Thus, close patient monitoring is necessary following fibrinolytic administration.
An understanding of fibrinolytics in the ED setting is essential, including the indications, contraindications, and dosing.
几种与血栓形成相关的危及生命的疾病包括急性缺血性卒中（AIS）、急性心肌梗死（AMI）和急性肺栓塞（PE）。纤维蛋白溶解剂是这些疾病治疗方案的一部分。
本叙述性综述为急诊临床医生提供在急诊科（ED）环境中用于AIS、AMI和PE的纤维蛋白溶解剂的概述。
病理性血栓形成可导致血管阻塞和栓塞，最终导致终末器官损伤。纤维蛋白溶解剂是用于溶解血凝块、改善血管血流的药物。最初使用的药物之一是链激酶，但随着包括阿替普酶（tPA）、替奈普酶（TNK）和瑞替普酶（rPA）在内的纤维蛋白特异性药物的出现，链激酶的使用频率降低。这些药物是几种疾病管理中的重要组成部分，包括AIS、AMI和PE。在出现可测量神经功能缺损3 - 4.5小时内且无脑出血（ICH）或其他禁忌证的AIS患者可能有资格接受tPA或TNK治疗。在没有经皮冠状动脉介入治疗（PCI）的情况下，对于出现胸痛至少30分钟但少于12小时的AMI患者应考虑使用纤维蛋白溶解剂，尽管在长达24小时时也可考虑使用。与AIS和PE不同，接受纤维蛋白溶解剂治疗的AMI患者应同时给予抗凝和抗血小板药物。在使用纤维蛋白溶解剂后，通常需要进行PCI。对于高危PE（血流动力学不稳定）患者推荐使用纤维蛋白溶解剂，因为它们可降低死亡风险。纤维蛋白溶解剂给药后最显著的并发症包括大出血，如ICH，与AMI和PE相比，AIS患者中发生大出血的频率最高。因此，在纤维蛋白溶解剂给药后需要密切监测患者。
了解急诊科环境中的纤维蛋白溶解剂至关重要，包括适应证、禁忌证和剂量。
