A 65-year-old woman is brought to the hospital for severe chest pain that started 7 hours ago. She was hospitalized 6 weeks ago with ischemic stroke and treated with aspirin and rosuvastatin. During that hospitalization, the patient had paroxysmal atrial fibrillation and was started on warfarin therapy. Her last INR 2 days ago was 2.1. The patient has mild, residual left-sided weakness. Her past medical history is also significant for hypertension.
Blood pressure is 165/90 mm Hg and heart rate is 98/min and regular. Chest examination shows crackles at the lung bases.
Electrocardiogram (ECG) shows normal sinus rhythm with 2 mm ST-segment elevation in leads V1-V4.
Which of the following is an absolute contraindication to fibrinolytic therapy in this patient?

Question

A 65-year-old woman is brought to the hospital for severe chest pain that started 7 hours ago.  She was hospitalized 6 weeks ago with ischemic stroke and treated with aspirin and rosuvastatin.  During that hospitalization, the patient had paroxysmal atrial fibrillation and was started on warfarin therapy.  Her last INR 2 days ago was 2.1.  The patient has mild, residual left-sided weakness.  Her past medical history is also significant for hypertension.
Blood pressure is 165/90 mm Hg and heart rate is 98/min and regular.  Chest examination shows crackles at the lung bases.
Electrocardiogram (ECG) shows normal sinus rhythm with 2 mm ST-segment elevation in leads V1-V4.
Which of the following is an absolute contraindication to fibrinolytic therapy in this patient?

Quizplus · Accepted Answer

Acute ST-elevation myocardial infarction can be treated with fibrinolytic therapy (FT) or percutaneous coronary intervention. This patient has multiple contraindications to fibrinolysis. However, the only absolute contraindication is the occurrence of an ischemic stroke within the last 3 months. If the stroke had occurred more than 3 months prior to her presentation, it would be a relative contraindication to FT. Patients with a relative contraindication may still receive FT if the benefits outweigh the risks. Prior history of intracranial hemorrhage (time unlimited) is another absolute contraindication. (Choice A) Although aspirin or other antiplatelet inhibitors should not be administered in the first 24 hours after FT, it is not an absolute contraindication to fibrinolysis. (Choice B) Poorly controlled hypertension (systolic blood pressure >180 mm Hg and diastolic blood pressure >110 mm Hg) is a relative contraindication to thrombolysis. Therefore, this patient's blood pressure does not qualify as a contraindication. (Choice D) The mortality benefit from FT is greatest when it is given within the first 60-70 minutes of symptom onset. FT can be administered for up to 12 hours from onset of symptoms, but the benefit declines rapidly after this time. (Choice E) Warfarin therapy with an elevated INR is a relative contraindication to FT. The higher the INR, the greater is the risk for bleeding after fibrinolysis. This patient's INR is 2.1. However, it is not an absolute contraindication if the benefits outweigh the risks. Educational objective: Ischemic stroke is an absolute contraindication to fibrinolytic therapy if the stroke occurred within the last 3 months and a relative contraindication if it occurred more than 3 months ago. Prior history of intracranial hemorrhage (time unlimited) is also an absolute contraindication. __________ References: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary. (http://www.ncbi.nlm.nih.gov/pubmed/15358045)

A 65-Year-Old Woman Is Brought to the Hospital for Severe