Acute cardiovascular emergencies include Acute Ischemic Stroke and other cardiovascular spectrum of ST-segment– elevation myocardial infarction (STEMI), non-STEMI/unstable angina, out-of-hospital cardiac arrest (OHCA), acute aortic dissection (AAD), abdominal aortic aneurysm (AAA) and acute decompensated heart failure with or without cardiogenic shock. Acute Ischemic Stroke and ST-segment– elevation myocardial infarction (ACS-STEMI) is those treated with either thrombolytic therapy or other reperfusion strategies on top of optimal medical treatment. Acute Ischemic Stroke is the most common type of stroke accounting for about 85% and is mainly due to hypoperfusion of the brain tissue due to a blockage of blood vessels supplying that specific area of interest, causing focal neurologic deficit with or without aphasia, decreased mentation and respiratory embarrassment 1.
Thrombolytic agents are plasminogen activators which convert the proenzyme, plasminogen, into an active enzyme, plasmin, which digests fibrin to soluble degradation products. Inhibition of the fibrinolytic system occurs at the level of the plasminogen activator (mainly by plasminogen activator inhibitor-1, PAI-1) and at the level of plasmin (mainly by α2-antiplasmin). Thrombolytic therapy is particularly effective in the early hours of Acute Ischemic Stroke, and its benefits are well-established. In Acute Ischemic Stroke, thrombolytic therapy has been associated with better functional outcomes and reduced disability 2.
There are several types of thrombolytic agents that can be used in clinical practice, including alteplase, reteplase, tenecteplase, and streptokinase. Alteplase is the most commonly used agent for thrombolysis in Acute Ischemic Stroke, as it has been shown to be safe and effective in multiple clinical trials 3,4. In Ethiopia, thrombolytic therapy has been used to treat patients with Acute ischemic stroke since the early 2000s. However, the utilization of this therapy is still low in the country. A study conducted in 2015 found that only 2.3% of patients with Acute ischemic stroke in Ethiopia were treated with thrombolytic therapy (Gebremariam et al., 2015). According to a study conducted by the American Heart Association, approximately 30% of patients with Acute ischemic stroke in the United States are treated with thrombolytic therapy.
However, despite the benefits of thrombolytic therapy is well-established, there is potential risks. Bleeding, which is the main risk associated with thrombolytic therapy, can occur at the site of the infarct, as well as in other parts of the body. Therefore, careful patient selection is critical to ensure that the benefits of thrombolytic therapy outweigh the risks. Some patient profiles may point the possible increased risks of thrombolytic-related bleeding. These include recent surgery, presence of active bleeding, uncontrolled hypertension or a history of intracranial hemorrhage 5. Additionally, the time from symptom onset to treatment is an important factor to consider, as the effectiveness of thrombolytic therapy decreases over time, while the complication is still there. The greatest benefit, restoring blood flow to the regions of brain that are ischemic but not yet infarcted, occurs when thrombolysis is initiated within 3 hours of the onset of symptoms, although it exerts definite benefit when begun within 4.5 hours 6.