Shock Syndromes II

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

“contraindications” noted in the product labeling, other than active internal bleeding, may be

considered “relative contraindications” 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 ≥ 175 mm Hg and/or DBP ≥ 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: