Pengantar Fibrinolitik
dr. Rizal Muhammad, Sp.JP, FIHA
KSM Kardiologi dan Kedokteran Vaskular
Rumah Sakit Umum Pusat Surabaya
Thrombolytic Therapy
• Thrombolytics or fibrinolytic are a group of medications used to
manage and treat dissolving intravascular clots.
• They are in the plasminogen activator class of drugs.
Baig MU, Bodle J. Thrombolytic Therapy [Internet]. StatPearls. 2025. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27606554
Indications
• Acute myocardial infarction (AMI)
• Deep vein thrombosis (DVT)
• Pulmonary embolism (PE)
• Acute ischemic stroke (AIS)
• Acute peripheral arterial occlusion
• Occlusion of indwelling catheters
• Intracardiac thrombus formation
Thrombolytic or Fibrinolytic Agents
• Alteplase
• Reteplase
• Tenecteplase
• Streptokinase
• Urokinase
Thrombolytic or Fibrinolytic Agents
Non-fibrin-specific: Fibrin-specific:
Beta hemolytic bacteria Derived from tPA:
proteins: • Alteplase
• Streptokinase • Reteplase
• Tenecteplase (Highest affinity
Produced by renal parenchymal for fibrin, longer half life,
cells: resistant to tPA-inhibitor 1)
• Urokinase
Streptokinase
Not a plasminogen activator. Binds with free circulating plasminogen, forming a complex that converts
additional plasminogen to active plasmin.
Pro’s Con’s
• Low cost → widely used • Re-administration within six
worldwide. months is considered un-safe
• Good efficacy and safety (high antigenicity and
(inferior to alteplase). antistreptococcal antibody).
• Less intracranial hemorrhage • Produced from streptococcus,
compared to alteplase. often exerts febrile and other
allergic reactions.
• Reported dose-dependent
hypotension.
Edwards Z, Nagalli S. Streptokinase [Internet]. StatPearls. 2025.
Alteplase
Alteplase is the recombinant plasminogen activator and identical to native tPA, which is more fibrin-
specific with a plasma halflife of 46 minutes.
Pro’s Con’s
• Most often used in STEMI, • Substantial amount of
pulmonary embolism & acute circulating fibrin degradation
ischemic stroke. products has been observed
• Non-antigenic → seldom with a moderate risk of
associated with allergic bleeding.
manifestations.
• Theoretically, alteplase should
only be active on the surface of
a fibrin clot.
Reed M, Kerndt CC, Nicolas D. Alteplase [Internet]. StatPearls. 2025.
Tenecteplase (TNK-tPA)
Tenecteplase has higher fibrin specificity and a longer plasma half-life with final clearance, primarily
through hepatic metabolism.
Pro’s Con’s
• Similar efficacy as alteplase • High cost.
with lower risk of non-cerebral
bleeding.
• Lacks antigenicity and is more
comfortable to administer.
Zitek T, Ataya R, Brea I. West J Emerg Med [Internet]. 2020.
Mechanism of Action
Mechanism of Action
- Platelet Plug Formation
Mechanism of Action
- Coagulation Cascade
Mechanism of Action
- Coagulation Cascade
Administration “Door to Needle”
• “Door to Needle" time should be kept under 30 minutes to get the
maximum results.
• The greater the time necessary to deliver the therapy after the AMI
lessens its efficacy.
Administration Route
• Systemic administration through a peripheral IV
• Local release by a catheter after navigating to the clot site (CDT)
→ requiring cath-lab
Administration Checklist
Equipment & Medicine
• ECG machine • Antiplatelet • Pain medication:
• Blood pressure monitor agents: • Nitrates
• Aspirin • Morphine
• Oxygen therapy equipment • Clopidogrel • Statins:
• Large bore IV access and supplies • Fibrinolytic • Rosuvastatin
• Laboratory equipment for blood agents: • Atorvastatin
tests • Streptokinase • Simvastatin
• Alteplase
• Emergency crash cart • Medications for
• Tenecteplase potential
• Anticoagulants: complication:
• Heparin • Antiarrhythmics
• LMWH • Vasopressors
• Antihistamine
Preparation & Dilution
Streptokinase Alteplase Tenecteplase
1 vial: 1500000 IU 1 vial: 50 mg 1 vial = 50 mg
Dilution: NaCl 0.9% or D5W Dilution: NaCl 0.9% or D5W Dilution: incompatible with dextrose
Volume: up to 500 mL Volume: up to 100 mL (0.5 - 1 mg/mL)
Do not shake → foaming
Monitoring
• Subjective:
• Alleviated, persistent or worsening chest pain
• Objective:
• GCS → intracranial hemorrhage
• Blood pressure → shock
• Rhythm (monitor / ECG) → reperfusion / malignant arrhythmia
• Breathing → pulmonary edema
• Hypersensitivity
• Lab:
• CBC, SE, RFT, LFT, haemostasis, glucose, lipid profile
• BGA (if presenting with hypoxia / shortness of breath)
• Radiology:
• CXR
Successful Fibrinolysis
• Resolution of chest pain: within 90 minutes of starting fibrinolytic
therapy
• ST-segment resolution: by at least 50% within 90 minutes of
starting fibrinolytic therapy
• Reperfusion arrhythmias: such as accelerated idioventricular
rhythm or non-sustained VT may appear within 3 hours of starting
fibrinolytic therapy
Bendary A, Tawfik W, Mahrous M, Salem M. J Cardiovasc Thorac Res. 2017;9(4):209–14.
Wu C, Li L, Wang S, Zeng J, Yang J, Xu H, et al. BMC Cardiovasc Disord. 2023;23(1):1–10.
