p.36 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e806

binant plasminogen activator) has not been shown to improve survival compared with alteplase in patients with MI, but its convenient bolus dosing allows for greater ease of use.18 Adjunctive antiplatelet and/or anticoagulant therapies are indicated, regardless of the choice of fibrinolytic agent (Sections 4.3.2., “Oral P2Y12 Inhibitors During Hospitalization,” and 4.4, “Parenteral Anticoagulation”). Absolute and relative contraindications for fibrinolytic therapy are listed in Table 14. Patients should be transferred to a PCI-capable hospital after initiation of fibrinolytic therapy for routine coronary angiography (Section 5.3.2., “Coronary Angiography and PCI After Fibrinolytic Therapy”). Signs of failed reperfusion are discussed in Section 5.3.2.

5.3.2 Coronary Angiography and PCI After Fibrinolytic Therapy

Recommendations for Coronary Angiography and PCI After Fibrinolytic Therapy Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations

1 A 1 In patients with STEMI, transfer to a

PCI-capable center immediately after fibrinolytic therapy is recommended.1–5

1 B-R 2 In patients with STEMI with suspected

failed reperfusion after fibrinolytic therapy, immediate angiography with rescue PCI is recommended to reduce the risk of death or recurrent MI.*6–9

1 B-R 3 In patients with STEMI treated with fibrino-

lytic therapy, early angiography between 2 and 24 hours with the intent to perform PCI is recommended to reduce the rates of death or MI.*1–5,10,11

*Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”12

Synopsis Failure of reperfusion and risk of reocclusion after successful fibrinolytic therapy are important limitations of fibrinolytic therapy. For this reason, all patients receiving fibrinolytic therapy should be transferred to a PCI-capable hospital to facilitate immediate or early catheterization depending on the clinical circumstances. Hospitals should have transfer protocols in place to allow for a seamless transfer to the PCI-capable facility as soon as it is safe to do so. A detailed assessment of clinical status is critical to determine the timing of angiography. A lack of improvement in ischemic symptoms, persistent ST-segment elevation (<50% resolution of ST-segment elevation in the anterior leads or <70% in inferior leads [measured either from the lead with maximal baseline ST elevation or as the sum of ST-segment deviation across leads]),13 or hemodynamic or electrical instability can indicate incomplete reperfusion by fibrinolytic therapy.14 When there are signs of failed reperfusion, patients should undergo immediate coronary angiography and rescue PCI. For the remaining patients, routine coronary angiography within 2 to 24 hours after fibrinolytic therapy with coronary revascularization as needed is recommended.

Table 14.  Absolute and Relative Contraindications for Fibrinolytic Therapy in STEMI* Absolute Contraindications Any prior ICH Known structural cerebral vascular lesion (eg, arteriovenous malformation) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke within 3 mo except acute ischemic stroke† Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed-head or facial trauma within 3 mo Intracranial or intraspinal surgery within 2 mo Severe uncontrolled hypertension (unresponsive to therapy) (SBP >180 mm Hg or DBP >110 mm Hg) Relative Contraindications History of chronic, severe, poorly controlled hypertension Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) History of prior ischemic stroke >3 mo Dementia Known intracranial pathology not covered in absolute contraindications Traumatic or prolonged (>10 min) CPR Major surgery (<3 wk) Recent (within 2 to 4 wk) internal bleeding Noncompressible vascular punctures Pregnancy Active peptic ulcer Oral anticoagulant therapy *Viewed as advisory for clinical decision-making and may not be all-inclusive or definitive. †Acute ischemic stroke within 4.5 h of onset. CPR indicates cardiopulmonary resuscitation; DBP; diastolic blood pressure; ICH, intracranial hemorrhage; SBP, systolic blood pressure; and STEMI, ST-segment elevation myocardial infarction.

Table 13.  Fibrin-Specific Fibrinolytic Agents for STEMI Fibrinolytic Agent Dose Tenecteplase (TNK-tPA) Single IV weight-based bolus* Reteplase (rPA) Two 10-unit IV boluses given 30 min apart (administered over 2 min) Alteplase (tPA) 90-min weight-based infusion† Streptokinase is no longer available in the United States. *30 mg for weight <60 kg; 35 mg for 60-69 kg; 40 mg for 70-79 kg; 45 mg for 80-89 kg; and 50 mg for ≥90 kg. †Adults ≥67 kg: 100-mg total dosage administered as a 15-mg IV bolus, followed by 50-mg IV infused over 30 min, and then 35-mg IV infused over the next 60 min. Adults <67 kg: 15-mg IV bolus, followed by 0.75 mg/kg IV (not to exceed 50 mg) infused over 30 min, and then 0.5 mg/kg IV (not to exceed 35 mg) over the next 60 min. rPA indicates reteplase plasminogen activator; TNK-tPA, tenecteplase tissuetype plasminogen activator; and tPA, tissue-type plasminogen activator.

Downloaded from http://ahajournals.org by on October 7, 2026