Associate Director, Cardiology, Max Hospital, Gurugram
Part 7 of 10 in Diagnosis and Management of Ischemic Heart Disease
Thrombolytic Drugs and When Thrombolysis Should Not Be Used
September 4, 2026
Thrombolysis buys time when a catheterization lab is out of reach, but Dr. Rohit Goel was equally clear that it is not a default option: the drug choice and the contraindication list both matter as much as the decision to thrombolyze at all.
The four thrombolytic agents
Dr. Goel named four molecules in current use: streptokinase, reteplase, tenecteplase and alteplase. Streptokinase is the cheapest but least effective of the four; reteplase, tenecteplase and alteplase all have better efficacy but cost considerably more. As he described the dosing, streptokinase is given as roughly 1.5 lakh units over about an hour, reteplase as a 10 mg bolus followed by a second 10 mg dose 30 minutes later, tenecteplase as a single weight-based bolus of 30 to 50 mg, and alteplase as 100 mg infused over about 2 hours.
When not to thrombolyze
Dr. Goel listed a long set of contraindications that referring doctors should check before giving any thrombolytic: a stroke within the last 2 months, any history of hemorrhagic stroke, head trauma in the past 4 weeks, recent surgery including dental extraction within 2 weeks, lumbar puncture within 4 weeks, active peptic ulcer or another cause of gastrointestinal bleeding, concurrent anticoagulation unless the INR is under 2, liver disease, a clotting disorder, pregnancy, acute pancreatitis, aortic dissection, active pulmonary tuberculosis with lung cavities, esophageal varices, a history of a brain tumor, or blood pressure above 200/120.
Why the dissection check matters most
Of all these, Dr. Goel singled out aortic dissection as the contraindication with the highest stakes: thrombolysis given to a patient with an undiagnosed dissection can trigger sudden cardiac arrest and worsen the dissection itself. A chest X-ray, used to distinguish dissection from a straightforward heart attack, is worth the extra minutes before committing to thrombolysis.
This article is based on a Jivo Masterclass session conducted by Dr. Rohit Goel, Principal Consultant, Cardiology, Max Hospital, Gurgaon. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a cardiology consultation or a second opinion on ischemic heart disease? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass — Dr. Rohit Goel taught doctors across Africa on June 1, 2025.
FROM THE LIVE Q&A
Doctor on the call (name unclear from transcript)
Is cardiac ultrasound of no importance in ischemic heart disease, and could you give a summary of its management?
Dr. Rohit Goel
Cardiac echo is important and is now done routinely, alongside cardiac enzymes and ECG, in suspected cases of heart attack at every tertiary care hospital where it is available. In summary, once ischemic heart disease is confirmed, every patient is loaded with aspirin (325 mg) along with clopidogrel (300 mg), prasugrel (60 mg) or ticagrelor (180 mg), a statin (atorvastatin or rosuvastatin, 40 to 80 mg), a beta blocker if blood pressure and heart rate allow, and glyceryl trinitrate for pain relief alongside oxygen. From there, ST-elevation MI patients receive heparin ahead of primary angioplasty, or are thrombolyzed if angioplasty is unavailable; non-ST-elevation MI and unstable angina patients are managed medically with low molecular weight heparin or fondaparinux instead of thrombolysis, and are escalated to coronary angiography and angioplasty or bypass surgery if they are high-risk or not improving.
Frequently Asked Questions
Can myocardial bridging cause acute coronary syndrome, or can it be a risk factor?▼
Myocardial bridging can cause chest pain and can act as a risk factor. The initial approach is medical management with beta blockers, calcium channel blockers or nitrates. If the patient's chest pain continues despite medication, the next step is bypass surgery rather than angioplasty, since angioplasty is not successful in a bridged segment of artery.
What is the safety of these ACS drugs in pregnancy?▼
Aspirin, clopidogrel, statins and beta blockers are all safe in pregnancy and can be used without hesitation. Low molecular weight heparin is also safe. ACE inhibitors should not be given, and thrombolysis is contraindicated outright in pregnant patients; these patients should instead be referred for primary angioplasty. The mother's life takes priority, though the fetal risk should be explained to the family before proceeding.
Can you elaborate more on glycoprotein 2b3a inhibitors and low molecular weight heparin?▼
There are three glycoprotein 2b3a inhibitors: abciximab, tirofiban and eptifibatide. These were used far more commonly a decade ago, before stents and catheterization labs were as standardized and widely available as they are now. Today their use has decreased and they are reserved for high-risk patients, such as those with a high thrombotic burden or delayed presentation, because of the increased risk of bleeding in the brain, stomach and at the local puncture site.
What is the prognosis of patients with ST-elevation MI if thrombolysis is not done, especially when there are contraindications?▼
The prognosis is poor when a patient with ST-elevation MI cannot be thrombolyzed because of a contraindication. Ideally these patients should be sent for primary angioplasty; if that is also unavailable, they should be managed medically in an ICU with aspirin, clopidogrel or ticagrelor, statins, beta blockers, ACE inhibitors, nitrates and heparin or low molecular weight heparin, using whatever resources are available. Outcomes can be described as roughly 50/50: some patients respond well to this treatment, while others deteriorate and need referral to a higher-level facility.
What is the approach for aortic dissection presenting like acute coronary syndrome?▼
Management of aortic dissection depends on which part of the aorta is involved. If the dissection involves the ascending aorta or the arch, it needs surgical management. If it involves the descending thoracic aorta or the descending abdominal aorta, percutaneous repair of the aneurysm is possible instead.
What are the four thrombolytic drugs used for STEMI?▼
Streptokinase, reteplase, tenecteplase and alteplase. Streptokinase is the cheapest but least effective; the other three cost more but work better.
What is the most dangerous contraindication to thrombolysis?▼
Aortic dissection. Thrombolyzing a patient with an undiagnosed dissection can cause sudden cardiac arrest and worsen the dissection, which is why a chest X-ray to rule it out is recommended first.
In This Series: Diagnosis and Management of Ischemic Heart Disease
- 1.Diagnosis and Management of Ischemic Heart Disease
- 2.Recognizing a Heart Attack: Classical and Atypical Symptoms of Acute Coronary Syndrome
- 3.ECG and Cardiac Biomarkers: The Two Investigations That Diagnose a Heart Attack
- 4.STEMI, Non-STEMI and Unstable Angina: How to Tell Them Apart
- 5.Emergency Drug Protocol for ST-Elevation Myocardial Infarction
- 6.Primary Angioplasty or Thrombolysis: Choosing the Right Reperfusion Strategy
- 7.Thrombolytic Drugs and When Thrombolysis Should Not Be Used
- 8.Managing Non-STEMI and Unstable Angina
- 9.Cardiac Rehabilitation, Follow-Up and Preventing the Next Heart Attack
- 10.Heart Attack Drugs in Pregnancy and Distinguishing Aortic Dissection from ACS