What are the AHA/ASA inclusion guidelines for fibrinolytic therapy with rt-PA for ischemic stroke?

Updated: May 27, 2020
  • Author: Edward C Jauch, MD, MS, FAHA, FACEP; Chief Editor: Helmi L Lutsep, MD  more...
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Therefore, if the patient is a candidate for fibrinolytic therapy, a thorough review of the inclusion and exclusion criteria must be performed. The exclusion criteria largely focus on identifying risk of hemorrhagic complications associated with fibrinolytic use. The American Heart Association/American Stroke Association (AHA/ASA) inclusion guidelines for the administration of rt-PA are as follows: [1]

  • Diagnosis of ischemic stroke causing measurable neurologic deficit

  • Neurologic signs not clearing spontaneously to baseline

  • Neurologic signs not minor and isolated

  • Symptoms not suggestive of subarachnoid hemorrhage

  • No head trauma or prior stroke in past 3 months

  • No myocardial infarction (MI) in past 3 months

  • No gastrointestinal/genitourinary hemorrhage in previous 21 days

  • No arterial puncture in a noncompressible site during the past 7 days

  • No major surgery in past 14 days

  • No history of prior intracranial bleeding

  • Systolic blood pressure under 185 mm Hg, diastolic blood pressure under 110 mm Hg

  • No evidence of acute trauma or bleeding

  • Not taking an oral anticoagulant, or if so, international normalized ratio (INR) under 1.7

  • If taking heparin within 48 hours, a normal activated prothrombin time (aPT)

  • Platelet count of more than 100,000/μL

  • Blood glucose greater than 50 mg/dL (2.7 mmol)

  • CT scan does not show evidence of multilobar infarction (hypodensity over one third hemisphere) or intracerebral hemorrhage

  • The patient and family understand the potential risks and benefits of therapy

Whereas these inclusion/exclusion criteria are from the original FDA approval, a more recent revision by the FDA of the product insert has reclassified many prevous absolute contraindications to now relative contraindications. Furthermore, subsequent data and experience have allowed some patients with what were previously considered relative contraindications to be safely treated. Involvement of a physician with stroke expertise is critical for assessing the risk/benefit consideration for these groups of patients.

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