Overview
Tissue plasminogen activator that converts plasminogen → plasmin → fibrinolysis. Used for STEMI, ischemic stroke, PE with hemodynamic instability. Time-critical administration.
Dosing
STEMI: 15mg bolus, then 0.75mg/kg over 30min (max 50mg), then 0.5mg/kg over 60min (max 35mg) Stroke: 0.9mg/kg (max 90mg) - 10% bolus, remainder over 1hr PE: 100mg over 2hr Max dose: 100mg
Pharmacokinetics
Onset: Immediate Peak: 30-60min Duration: 4-6hr Metabolism: Hepatic Elimination: Renal Half-life: 5min
Pharmacodynamics
Mechanism: Binds fibrin → converts plasminogen to plasmin → degrades fibrin clots Effects: - Fibrin-specific lysis - Systemic fibrinolysis at higher doses - Bleeding risk - Reperfusion injury possible
Clinical Considerations
Clinical Pearls: 1. Strict time goals (door-to-needle <30min for stroke) 2. Absolute contraindications include recent surgery/bleeding 3. Monitor for reperfusion arrhythmias (STEMI) 4. Have blood products available 5. No anticoagulation for 24hr after stroke treatment 6. Head CT mandatory before stroke treatment 7. Consider tenecteplase as alternative 8. Lower dose for low-weight patients