Shock Syndromes II
| (b) | Commonly used bleeding scores such as HAS-BLED moderately predict the risk of an |
|---|
intracranial hemorrhage after thrombolytic agents for PE but lack precision. HAS-BLED
has not been validated specifically for predicting thrombolytic-associated bleeding in PE
and should be used cautiously.
ix.
In extreme circumstances (e.g., massive PE with impending cardiac arrest), even the presence
of strong risk factors for bleeding may not preclude some clinicians from administering
thrombolytics because of the potential for benefit from the therapy. In these settings, even the
βcontraindicationsβ noted in the product labeling, other than active internal bleeding, may be
considered βrelative contraindicationsβ by some clinicians for thrombolytic administration.
Alteplase package insert contraindications
Active internal bleeding
Recent (within 3 mo) intracranial or intraspinal surgery or
serious head trauma
Current cerebrovascular accident (intracranial
hemorrhage or ischemic stroke)
Current severe uncontrolled hypertensiona
Malignant intracranial neoplasm, arteriovenous
malformation, or aneurysm
Known bleeding diathesisb
Alteplase package insert warnings
Recent major surgery
Significant closed-head or facial trauma with radiographic
evidence of bony fracture or brain injury within 3 mo
Cerebrovascular disease
Recent GI or genitourinary bleeding
Hemostatic defects (including those secondary to
severe hepatic or renal disease)
Hypertension (SBP β₯ 175 mm Hg and/or DBP β₯ 110 mm Hg)
Acute pericarditis
Subacute bacterial endocarditis
Recent trauma
Significant hepatic dysfunction
Age > 75
Needle puncture at noncompressible site
Left heart thrombus
Pregnancy
Septic thrombophlebitis or occluded
arteriovenous cannula at seriously infected site
Diabetic hemorrhagic retinopathy or other hemorrhagic
ophthalmic conditions
Recent receipt of oral anticoagulants
Bleeding risk factors reported in published literature
Recent internal bleeding
Suspected aortic dissection
Poorly controlled baseline hypertensiona
Acute pancreatitis
Acute myocardial infarction
Cardiopulmonary resuscitation > 10 min
Stool occult blood positive
Bilirubin concentration > 3 mg/dL
Presence of an intra-aortic balloon pump
Dementia
African American race
Coagulopathyb
aUndefined for PE, but noted as > 185 mm Hg systolic or > 110 mm Hg diastolic for acute ischemic stroke.
bUndefined for PE, but noted as INR > 1.7 or Plt < 100,000/mm3 for acute ischemic stroke.
Adapted with permission from: Curtis GC, Lam SW, Reddy AJ, et al. Risk factors associated with bleeding after alteplase administration for pulmonary embolism: