ClinCalc Pro
Menu
Calculators Drugs Pathways AI Dx Donate Get the App
Thrombolytic / STEMI Pregnancy: Use only for life-threatening indications (massive PE or STEMI) — risk of placental abruption and maternal haemorrhage. Specialist decision.

Alteplase (STEMI Thrombolysis)

Brand names: Actilyse

Adult dose

Dose: Accelerated regimen (preferred): 15 mg IV bolus, then 0.75 mg/kg over 30 min (max 50 mg), then 0.5 mg/kg over 60 min (max 35 mg). Total max dose: 100 mg.
Route: Intravenous
Frequency: Single treatment course
Max: 100 mg total
Recombinant tissue plasminogen activator (tPA). For STEMI when primary PCI not available within 120 minutes of first medical contact. Give with heparin (UFH or enoxaparin) and dual antiplatelet therapy. GUSTO-1 trial: accelerated alteplase superior to streptokinase.

Paediatric dose

Route: IV
Seek specialist opinion — paediatric stroke/thrombosis indications vary. BNFc for guidance.

Dose adjustments

Renal

No dose adjustment required

Hepatic

Use with caution in severe hepatic impairment (coagulopathy risk)

Clinical pearls

  • GUSTO-1 trial (GUSTO Investigators, NEJM 1993): accelerated alteplase vs streptokinase in STEMI — significantly lower 30-day mortality (6.3% vs 7.3%); lower intracranial haemorrhage with streptokinase but overall mortality favoured alteplase. Established accelerated alteplase as preferred thrombolytic.
  • Door-to-needle time target: <30 minutes for pharmacological thrombolysis (when PCI not available). Primary PCI is preferred if achievable within 120 minutes of first medical contact (ESC 2023).
  • Reperfusion markers: ST resolution >50% at 60-90 minutes + reperfusion arrhythmias (accelerated idioventricular rhythm) + relief of chest pain = successful reperfusion. If not reperfused — rescue PCI mandatory.
  • Contraindication assessment: absolute contraindications (intracranial bleed, aortic dissection) must be rapidly excluded. BP >180/110 — treat to <180/110 before giving thrombolysis. Relative contraindications require careful risk/benefit.
  • Half-dose alteplase in elderly: patients >75 years — some protocols use reduced dosing (0.6 mg/kg max 90 mg) to reduce intracranial haemorrhage risk.

Contraindications

  • Previous haemorrhagic stroke (any time)
  • Ischaemic stroke within 3 months
  • Active internal bleeding
  • Intracranial neoplasm, AVM, or aneurysm
  • Suspected aortic dissection
  • Recent major surgery or trauma within 3 weeks
  • Severe uncontrolled hypertension (>180/110 mmHg)
  • Infective endocarditis

Side effects

  • Intracranial haemorrhage (0.5-1% — most feared; higher risk in elderly, low body weight, hypertension)
  • Major GI/retroperitoneal bleeding
  • Reperfusion arrhythmias (accelerated idioventricular rhythm — benign marker of reperfusion)
  • Orolingual angioedema (rare)

Interactions

  • Anticoagulants/antiplatelets — additive bleeding risk; heparin and DAPT used concomitantly per protocol
  • ACE inhibitors — increased risk of angioedema with alteplase (particularly in stroke setting)

Monitoring

  • ECG continuously post-thrombolysis (reperfusion ST changes)
  • Blood pressure every 15 minutes for first 2 hours
  • Neurological status (intracranial haemorrhage — new headache, confusion, focal deficit = EMERGENCY)
  • Signs of major bleeding

Reference: BNFc; BNF 90; GUSTO-1 Trial (NEJM 1993); ESC STEMI Guidelines 2023; NICE NG185; SPC Actilyse. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Calculators
Drugs
Pathways