Thrombolytic drug

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Thrombolytic drugs are used in medicine to dissolve blood clots in a procedure termed thrombolysis. They limit the damage caused by the blockage of the blood vessel.

Uses

Thrombolysis is used in for myocardial infarction (heart attack), ischemic strokes, deep vein thrombosis and pulmonary embolism to clear a blocked artery and avoid permanent damage to the perfused tissue (e.g. myocardium, brain, leg) and death. A less frequent use is to clear blocked catheters that are used in long-term medical therapy.

It should be noted that thrombolytic therapy in hemorrhagic strokes is contraindicated, as its use in that situation would prolong bleeding into the intracranial space and cause further damage.

Members

The thrombolytic drugs include:

These drugs are most effective if administered immediately after it has been determined they are clinically appropriate. The advantage of administration is highest within the first ninety minutes, but may extend up to six hours after the start of symptoms.

The drugs are often given in combination with intravenous heparin, or low molecular weight heparin, which are anticoagulant drugs.

Side-effects

Hemorrhagic stroke is a rare but serious complication of thrombolytic therapy. If a patient has had thrombolysis before, an allergy against the thrombolytic drug may have developed (especially after streptokinase). If the symptoms are mild, the infusion is stopped and the patient is commenced on an antihistamine before infusion is recommenced. Anaphylaxis generally requires immediate cessation of thrombolysis.

Glycoprotein IIb/IIIa inhibitors	Abciximab • Eptifibatide • Tirofiban
ADP receptor/P2Y₁₂ inhibitors	(Thienopyridines) Clopidogrel • Ticlopidine • Prasugrel
Prostaglandin analogue (PGI2)	Beraprost • Prostacyclin • Iloprost • Treprostinil
COX inhibitors	Acetylsalicylic acid/Aspirin # • Aloxiprin • Carbasalate calcium
Other	Ditazole • Cloricromen • Dipyridamole • Indobufen • Picotamide • Triflusal

Anticoagulants

Vitamin K antagonists
(inhibit II, VII, IX, X)

coumarins: Acenocoumarol • Coumatetralyl • Dicoumarol (Dicumarol) • Ethyl biscoumacetate • Phenprocoumon • Warfarin

1,3-indandiones: Clorindione • Diphenadione • Phenindione

other: Tioclomarol

Factor Xa inhibitors
(with some II inhibition)

Heparin group/ glycosaminoglycans/ (bind antithrombin)	low molecular weight heparin (Bemiparin, Certoparin, Dalteparin, Enoxaparin, Nadroparin, Parnaparin, Reviparin, Tinzaparin) oligosaccharides (Fondaparinux, Idraparinux) heparinoid (Danaparoid, Sulodexide, Dermatan sulfate)
Direct factor Xa inhibitors	xabans (Apixaban, Otamixaban, Rivaroxaban)

Direct thrombin (II) inhibitors

bivalent: Hirudin (Bivalirudin, Lepirudin, Desirudin)
univalent: Argatroban • Dabigatran • Melagatran • Ximelagatran

Other

Defibrotide • Ramatroban • Antithrombin III • Protein C (Drotrecogin alfa)

Thrombolytic drugs/
fibrinolytics

plasminogen activators: TPA (Alteplase, Reteplase, Tenecteplase) • UPA (Urokinase, Saruplase) • Streptokinase # • Anistreplase • Monteplase

other serine endopeptidases: Ancrod • Fibrinolysin

Brinase

Non-medicinal

Citrate • EDTA • Oxalate

# = WHO-EM

v • d • e Major Drug Groups
Gastrointestinal tract (A)	Antacids • Antiemetics • H₂-receptor antagonists • Proton pump inhibitors • Laxatives • Antidiarrhoeals
Blood and blood forming organs (B)	Anticoagulants • Antiplatelets • Thrombolytics
Cardiovascular system (C)	Antiarrhythmics • Antihypertensives • Diuretics • Vasodilators • Antianginals • Beta blockers • Angiotensin converting enzyme inhibitors • Antihyperlipidemics
Skin (D)	Emollients - Antipruritics
Reproductive system (G)	Hormonal contraception • Fertility agents • Selective estrogen receptor modulators • Sex hormones
Endocrine system (H)	Anti-diabetics • Corticosteroids • Sex hormones • Thyroid hormones
Infections and Infestations (J, P)	Antibiotics • Antivirals • Vaccines • Antifungals • Antiprotozoals • Anthelmintics
Malignant and Immune disease (L)	Anticancer agents • Immunostimulators • Immunosuppressants
Muscles, Bones, and Joints (M)	Anabolic steroids • Anti-inflammatories • Antirheumatics • Corticosteroids • Muscle relaxants
Brain and Nervous system (N)	Anesthetics • Analgesics • Anticonvulsants • Mood stabilizers • Anxiolytics • Antipsychotics • Antidepressants • Nervous system stimulants • Sedatives
Respiratory system (R)	Bronchodilators • Decongestants • Antihistamines

v • d • e Electrocardiography
Overview	History of the EKG • EKG interpretation basics • Normal sinus rhythm
EKG Complexes	P wave • QRS complex • ST Segment • T wave • T wave alternans • Tombstone T wave • U wave Osborn wave • H wave • K wave • Delta wave NSSTW changes
EKG Intervals	PR Interval • QRS Interval • ST Interval • QT Interval
Conduction System & Bradycardia	Cardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block
Atrial Arrhythmias	Sinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker
Ventricular Arrhythmias	Differential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death
EKG Abnormalities in Disease States	Hypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy • Acute myocardial infarction • NSTEMI • STEMI • Tombstone ST elevation • Right ventricular myocardial infarction • Atrial infarction Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins • Congenital heart block Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome Inherited Disease • Brugada Syndrome Systemic Diseases • CNS Disease • Cardiac Tumors Heart Transplantation • EKG Changes in patient with Heart Transplantation Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries
Technical Issues and Potential Errors in Interpretation	Artifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker • EKG in athletes

v • d • e Circulatory system pathology (I, 390-459)
Hypertension	Hypertensive heart disease - Hypertensive nephropathy - Secondary hypertension (Renovascular hypertension)
Ischaemic heart disease	Angina pectoris (Prinzmetal's angina) - Myocardial infarction (heart attack) - Dressler's syndrome
Pulmonary circulation	Pulmonary embolism - Cor pulmonale
Pericardium	Pericarditis - Pericardial effusion - Cardiac tamponade
Endocardium/heart valves	Endocarditis - mitral valve (regurgitation, prolapse, stenosis) - aortic valve (stenosis, insufficiency) - pulmonary valve (stenosis, insufficiency) - tricuspid valve (stenosis, insufficiency)
Myocardium	Myocarditis - Cardiomyopathy (Dilated cardiomyopathy, Hypertrophic cardiomyopathy, Loeffler endocarditis, Restrictive cardiomyopathy) - Arrhythmogenic right ventricular dysplasia
Electrical conduction system of the heart	Heart block: AV block (First degree, Second degree, Third degree) - Bundle branch block (Left, Right) - Bifascicular block - Trifascicular block Pre-excitation syndrome (Wolff-Parkinson-White, Lown-Ganong-Levine) - Long QT syndrome - Adams-Stokes syndrome - Cardiac arrest - Sudden cardiac death Arrhythmia: Paroxysmal tachycardia (Supraventricular, AV nodal reentrant, Ventricular) - Atrial flutter - Atrial fibrillation (Familial) - Ventricular fibrillation - Premature contraction (Atrial, Ventricular) - Ectopic pacemaker - Sick sinus syndrome
Other heart conditions	Heart failure - Cardiovascular disease - Cardiomegaly - Ventricular hypertrophy (Left, Right)
Cerebrovascular diseases	Stroke - Transient ischemic attack - Intracranial hemorrhage/cerebral hemorrhage: Extra-axial hemorrhage (Epidural hemorrhage, Subdural hemorrhage, Subarachnoid hemorrhage) Intra-axial hematoma (Intraventricular hemorrhages, Intraparenchymal hemorrhage) - Anterior spinal artery syndrome - Binswanger's disease - Moyamoya disease
Arteries, arterioles and capillaries	Atherosclerosis (Renal artery stenosis) - Aortic dissection/Aortic aneurysm (Abdominal aortic aneurysm) - Aneurysm - Raynaud's phenomenon/Raynaud's disease - Buerger's disease - Vasculitis/Arteritis (Aortitis) - Intermittent claudication - Arteriovenous fistula - Hereditary hemorrhagic telangiectasia - Spider angioma - Dissection (Carotid artery, Vertebral artery)
Veins, lymphatic vessels and lymph nodes	Thrombosis/Phlebitis/Thrombophlebitis (Deep vein thrombosis, May-Thurner syndrome, Portal vein thrombosis, Venous thrombosis, Budd-Chiari syndrome, Renal vein thrombosis, Paget-Schroetter disease) - Varicose veins / Portacaval anastomosis (Hemorrhoid, Esophageal varices, Varicocele, Gastric varices, Caput medusae) - Superior vena cava syndrome - Lymph (Lymphadenitis, Lymphedema, Lymphangitis)
Other	Hypotension (Orthostatic hypotension) - Rheumatic fever
See also congenital (Q20-Q28, 745-747)