Today there are 3 generations of medicines that perform thrombolysis, which are essentially various from each various other in regards to their system of activity and level of security, which are normally thought about when suggesting medicines.
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Thrombolytic medicines of plasma beginning have a straight proteolytic impact on fibrin. The earliest medicines are extremely efficient, for which you need to pay severe problems. Used just when there are just nothing else choices:
- Fibrinolysin – separated from human plasma profibrinolysin. The medication is direct-acting, ineffective sufficient, gradually lysing arterial thrombi. Applied with contraindications to various other thrombolytic medicines. The rate is 1450 rubles.
- Streptokinase (Cabikinase, Celiasis, Thromboflux) – an item of the task of streptococci. Very unsafe medication with unparalleled performance. It acts quickly on all parts of the blood coagulation system, greatly minimizes the thickness of the organic liquid, triggers hefty blood loss at the tiniest mistake in the dosage. Before the visit, you must examine the client’s problem, consider all the pros and disadvantages. The price of Streptokinase is 1050 rubles, Thromboflux – 3 150 rubles.
- Urokinase – initially separated from human pee, thus the name. Non-discerning representative, acts effective, yet disrespectful, is utilized with care. It impacts primarily fibrin. Demonstrates antiaggregant residential properties, improves delicacy of capillary. The rate is 1 rubles.
In technique, they additionally make use of APSAC (acetylated plasminogen-streptokinase complicated) – an analogue of Streptokinase, varies by the opportunity of intravenous jet management.
The 2nd generation
Indirect thrombolytic medicines “work” with plasminogen, are more secure than the very first generation, are thought about the gold requirement of thrombolysis:
- Actilase (Actilize) – has a careful impact, as it impacts the forerunner of plasmin, which lies in a thrombus and is linked with fibrin. The rate is 15 000 rubles.
- Alteplase – the highlight – a specific area of application: with a heart attack, stroke, lung blood clot – as component of the primary treatment and to stop regression. Used in kids and the senior, expectant and breast feeding moms. The danger of blood loss is significantly reduced. Cost – 22 300 rubles.
- Prourokinase (Purolyase) – is made from DNA recombinant cells of the kidneys of a human embryo, created in 2 kinds: non-glycolized recombinant prourokinase (saruplase) glycolized recombinant prourokinase. Both kinds work, glycosylated acts much faster. The dangers of deadly blood loss linger. Cost – 8500 rubles.
Modern thrombolytics are a mix of very first and 2nd generation medicines that have actually taken their finest residential properties. The danger of blood loss is decreased:
- Retaplase (Lanoteplase, Antistreplase) is a specialized medication with fibrinolytic impact, lyses embolism, recovers blood circulation in coronaries. It is shown after AMI or for the avoidance of anemia with partial obstruction of the vessel. Cost – 26 600 rubles.
- Tenecteplase (Metalysis) – the most recent generation of fibrinolytic for the therapy of apoplexy after a stroke, heart attack, previous injuries, lung blood clot. The rate is 25 000 rubles.
- Staphylokinase (Fortelizin) – among one of the most efficient medicines manufactured from stress of Staphylococcus aureus, is not allergenic. When utilizing the device, not a solitary deadly result was kept in mind. Cost – 16 600 rubles.
Acquaintance with fibrinolytic representatives and their usage started in the center of the last century. Since after that, these medicines have actually been slowly boosted, and today, according to the system of activity, thrombolytics are split right into 4 teams, which are additionally called generations. Despite the truth that brand-new medicines are thought about one of the most efficient, the old ones are still utilized with no much less performance.
The very first generation consists of the supposed all-natural all-natural enzymes, these medicines are additionally called systemic. They add to the activation of all-natural procedures that boost the body’s all-natural action to embolism. The intricacy of using such medicines is that, to start with, they can create anaphylactic shock, like international healthy proteins, and second of all, they can create blood loss, because they trigger the whole quantity of the blood enzyme. The most renowned are Streptokinase, Urokinase, Streptodekase and Fibrinolysin.
The 2nd generation of thrombolytics is developed utilizing genetic modification and biotechnology. They enable the preferred genetics to be presented right into E. coli germs, as an outcome of which the preferred material is manufactured. The distinction in between second-generation and first-generation medicines is that just those enzymes are entailed that are local straight at the shot website.
The 3rd generation is much more innovative, because it was feasible to accomplish a much longer activity of the energetic parts and their discerning impact straight on the thrombus. The most renowned of the 3rd generation are Tenecteplase, Lanoteplase and Reteplase. The 4th generation consists of consolidated medicines that act much more promptly, precisely and constantly, an instance is Urokinase-Plasminogen.
Thrombolytic treatment for ischemic stroke, heart attack and various other illness can be systemic or neighborhood. In the very first situation, the medication is infused right into a capillary and spreads out via the blood stream throughout the network, while the shipment of energetic parts to the thrombus takes a lot longer. Local management is arranged utilizing a catheter, and the medication is carried out straight to the embolism, adding to quick thrombolysis.
Method of carrying out
One of one of the most unsafe pathologies of the cardio system is ischemic stroke, which calls for one of the most efficient therapy in the very first hrs after the beginning.
One of the techniques for this is thrombolysis, which is always consisted of in the therapy program for ischemic stroke in the onset. This technique is based upon the intro right into the client’s blood of medicines that create embolism damage and enhance blood make-up.
Purpose of the treatment
- Ischemic stroke is an infraction of analytical flow with damages to the mind as a result of the truth that blood does not go into well or does not go into whatsoever in among its divisions.
- It is gone along with by a conditioning of component of the mind cells (analytical infarction).
- The factor might be a reduction in blood circulation in the vessels of the mind, apoplexy or blood clot, which appear as a result of diseases of the cardiovascular system and blood.
- Mortality from it is about 20% of the total number of patients.
- Sometimes the name “cerebral infarction” may occur.
This method is most effective in the first hours after a stroke, at a later date it is not used. Naturally, for his appointment, there are a number of indications and contraindications.
According to the clinical protocol, thrombolytic therapy is divided into drug and mechanical.
The following indications for the use of TLT are:
- no more than 3 to 6 hours have passed since the onset of symptoms;
- on CT and MRI, the picture of ischemic stroke is clearly visible;
- pronounced neurological deficit, i.e. symptoms indicating damage to a portion of the mind;
- lack of general contraindications.
The treatment protocol indicates such contraindications:
- aortic dissection;
- cerebrovascular accident in the last 2 months;
- a major operation that was performed less than three weeks ago;
- multiple myocardial infarction with severe cardiosclerosis;
- aggravation of peptic ulcer disease;
- cirrhosis of the liver;
- hypertension, in which the pressure practically does not fall below 180/100;
- taking medications that reduce blood coagulability;
- recent retinal laser therapy;
- streptokinase allergy that has occurred over the past two years.
Important! Hemorrhagic stroke or subarachnoid hemorrhage in the last six months, any active bleeding in the last month are absolute contraindications for the procedure. Because drugs break down all blood clots, not only recently appeared.
Currently, three generations of drugs are used for thrombolysis.
The first generation is Streptokinase and Urokinase. These drugs are rarely used due to the high risk of complications after their use. Streptokinase is administered over an hour. When applying Urokinase, heparin must be administered intravenously. Both drugs are administered drip.
Important! Streptokinase is not compatible with the human body and often causes acute allergic reactions. With the use of Urokinase, this is rarely observed.
The second generation includes Aktilize (Alteplase) and Prourokinase. The first drug must be administered in the first 4 to 5 hours after a stroke. Dosage of 0,9 mg per 1 kg of patient weight, but not more than 90 mg. A tenth of the dose is administered jet, and the remainder is drip.
Prourokinase is used in the first 6 hours of the disease, but in some cases it is permissible to use it for up to 12 hours. Introduced in 3 to 6 minutes. There are two forms of drug release non-glycated and glycosylated. Glycated acts faster.
The third generation includes Metalysis (Tenecteplase), Retiplase and Anestriplase. Drugs of this generation are injected in a jet, usually it takes about 10 seconds.
The dosage of metalysis depends on the weight of the patient. Up to 60 kg – 30 mg, 80 – 90 kg – 45 mg. The effect of the drug is enhanced by Heparin and Acetylsalicylic acid (Aspirin). Retilase according to the treatment regimen is administered in two doses.
The second injection of the drug is carried out half an hour after the first. Anistreplase is a complex drug consisting of streptokinase with plasminogen, which provides a quick effect on a blood clot. Once administered, 30 units of the drug.
Reference! These drugs dissolve blood clots, but do not prevent their further formation. Most likely, the patient will be prescribed a course of drugs that reduce blood coagulation after thrombolysis.
According to international studies, the effectiveness of thrombolytic therapy for ischemic stroke depends on the time elapsed after the onset of the disease.
In general, it can be said that when such treatment is carried out for up to 4,5 hours, the improvement in the condition of patients is 30% higher than without it. The best result is achieved if treatment begins no later than three hours later.
- At the same time, mortality and the likelihood of irreversible brain damage leading to disability are significantly reduced.
- Before agreeing to such treatment, it is absolutely necessary to require CT / MRI as soon as possible, because bleeding should be excluded, and every minute of the course of the disease will be counted.
It is also necessary to tell the doctor about all the diseases of the patient for a period of two years, even if it seems insignificant. If possible, insist on therapy with the latest generation of drugs to dissolve the thrombus as quickly as possible.
The use of methods of CT (MR) angiography and / or CT (MRI) – perfusion studies is advisable if they are technically feasible without delaying the onset of IV transplantation (i.e., starting the infusion of thrombolytic in the CT room), and may be in demand outcome or beyond 4,5 hours, if in the conditions of this center endovascular treatment of ischemic stroke is available (intra-arterial thrombolysis, thromboembolectomy).
Tasks of laboratory diagnostics in patients with a presumptive diagnosis of a stroke: to determine the parameters of a clinical blood test, including obligatory before TLT (platelet count, glucose; APTT when using heparin in the previous 2 days and INR when taking warfarin before the development of this disease) Thrombolysis is carried out only in conditions of BITR (monitoring of blood pressure, heart rate, NPV, t, spo2)
The use of multimodal neuroimaging in some cases can be used to make a decision regarding patients whose exact time for the onset of a stroke is unknown, but is not recommended as a routine clinical practice.
Coronary heart disease accounts for 53% of the population mortality structure, of which 13% die from myocardial infarction, the most dangerous pathological condition requiring urgent medical intervention. In 2015, about 63 thousand people died of a heart attack in Russia.
The cause of heart pathology in the vast majority of cases is coronary artery thrombosis, due to which myocardial cells die.
For successful treatment of a heart attack, it is necessary to immediately restore coronary blood flow, since necrosis of myocardial cells develops within 4-6 hours.
In countries with a large territory and poorly developed transport infrastructure, including Russia, the implementation of PCI is difficult because most patients do not immediately go to hospitals that can provide them with the necessary therapy.
If performing percutaneous coronary intervention as soon as possible is impossible, the only alternative method for restoring blood flow is thrombolytic therapy – a treatment method consisting in the introduction of a drug that dissolves a blood clot into a blood vessel.
Thrombolytic therapy allows to halve the mortality of patients with acute myocardial infarction. According to the Ministry of Health of the Russian Federation, in 2015
about 30 thousand thrombolysis was carried out in case of myocardial infarction: behind these figures are the lives of real people who received a chance of salvation thanks to innovative drugs.
The recognized “gold standard” of thrombolytic therapy is the innovative Beringer Ingelheim products, the effectiveness and safety of which have been proven in international clinical trials involving hundreds of thousands of patients.
Recently, vascular diseases of the brain, in particular acute ischemic stroke, are becoming more widespread. According to the National Register, in 2015 about 420 thousand Russians suffered an ischemic stroke.
Modern thrombolytic therapy is recommended for use in this disease, and its effectiveness in strokes is clinically confirmed. Using thrombolysis, you can restore blood supply to damaged areas, reduce the size of the lesion of the brain or prevent its development.
Russian medicine has an urgent need for the development of thrombolytic therapy, which will help significantly reduce mortality and disability due to CVD, contributing to the speedy implementation of the Federal Program for Medical Care for Cardiovascular Diseases and the Program for the Development of the Emergency Medical Aid System in the Russian Federation.
When analyzing various clinical studies involving more than 6000 patients who underwent thrombolysis at the prehospital stage or in the hospital, a significant decrease in the early mortality rate (17%) was found during thrombolysis at the prehospital stage.
In a meta-analysis of 22 clinical trials, a more significant decrease in mortality was found in those patients who underwent thrombolysis within 2 hours from the onset of clinical manifestations compared with later dates.
In coronary infarction, a systemic procedure can be performed.
They are extremely rare, but dangerous by the development of hemorrhages, both external and internal (bruises, bruises). In addition, as a result of the introduction of fibrinolytics, there are:
- allergic reactions, skin rash, urticaria;
- tissue pastiness;
- hypotension, vascular collapse;
- shock of various etiologies;
- heart tamponade;
- intrahepatic or pulmonary bleeding;
- thrombosis and vascular blood clot;
- mucosal bleeding;
- gastric and intestinal bleeding;
- impurities of blood in vomit, feces, urine.
To find out whether it was possible to achieve the result of treatment with thrombolytics, the doctor should prescribe instrumental examination methods. Most commonly used are magnetic resonance imaging (MRI) and computed tomography (CT). Also, 1-2 hours after administration of the drug, coronary angiography is performed. This is a method for examining the coronary arteries that feed the heart using x-ray radiation with the preliminary introduction of a contrast agent into the vessel. There are several degrees of effectiveness:
- 0 – contrast does not move along the clogged vessel;
- 1 – a small amount of contrasting substance passed through a blood clot;
- 2 – more than half of the contrast passed through the thrombosed area;
- 3 – patency is fully restored, the contrast moves through the circulatory network.
Not for all patients, thrombolytic therapy becomes effective, in some cases complications arise – allergic reactions, low blood pressure, bleeding, fever. If such conditions occur, you can not self-medicate, you need to see a doctor.
Efficacy and Complications
Thrombolytic therapy, depending on the degree of damage and associated problems, can cause unwanted reactions. The most common complications:
- A sharp decrease in pressure. It is the result of the action of “Streptokinase”.
- Fever and trembling. Apply antipyretic.
- Allergy, which is manifested by skin rash. In difficult cases, for symptomatic treatment, the doctor treats with hormones.
- Small or heavy bleeding at the site of catheter insertion. Causes a decrease in hemoglobin and platelets.
- Cerebral hemorrhage.
- Russian clinical guidelines for the diagnosis, treatment and prevention of venous thromboembolic complications (VTEC). Phlebology. 2015.
- Chazova I.E., Martynyuk T.V. Clinical recommendations for the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (Part I). Therapeutic Archive. 2016.
- Duranteau J., Taccone FS, Verhamme P., Ageno W. European gu>
Higher medical education. 30 years of working experience in practical medicine.
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Last Updated: October 7, 2019
Modern medicine has invented an effective way to rehabilitate patients in the event of ischemic stroke or coronary infarction. After therapy with thrombolytics, the patient regains basic functions within a short time, if he strictly follows all the recommendations of the doctor. The main condition remains the speed of therapy, that is, the shorter the time between an attack of the disease and thrombolysis, the more effective the result. If the time losses are too large, the affected areas die off and there is no way to restore them.
General information about thrombolysis
In the body of each person, a natural process of thrombolysis occurs. It is carried out using special enzymes in the blood. But these substances are not able to fully cope with large blood clots. They are effective only in the presence of small blood clots.
As a result, large clots formed block the lumen of the vessel in whole or in part. Because of this, circulatory failure occurs, which leads to starvation of the body’s cells and even their death. This phenomenon disrupts the functioning of internal organs.
Therefore, the question arises, how to dissolve a blood clot? To solve this problem, apply artifact thrombolysis. The essence of the technique is that the doctor injects medications into the veins, which are designed to dissolve blood clots.
Thrombolytic treatment is carried out in two ways:
- Systemic Its peculiarity is that it does not matter where the blood clot is located. The medicine spreads throughout the body along with blood and eventually collides with a blood clot, dissolving it. But this method of thrombolysis has one drawback – the need to use a large dosage of the drug, which negatively affects the circulatory system.
- Local. This method is characterized in that the medicine is administered directly to the area where the blood clot is located. The drug is delivered to the vessel using a catheter. This method is quite complicated, the implementation is controlled by an x-ray machine.
Which method to prefer when performing thrombolytic treatment is decided by the attending physician for each patient individually.
Where is thrombolytic therapy performed? Treatment can be carried out both at home and after hospitalization. Emergency thrombolytic treatment is the most effective, since it has an advantage with respect to time. After all, the sooner the procedure is completed, the more chances there are to save a person.
In this regard, hospital thrombolysis has a significant drawback. It is prescribed only after the patient is fully examined. Therefore, the speed of therapy is lower, but it is possible to check for contraindications to the use of thrombolytics, which avoids many adverse complications.
A stroke of the brain is a dangerous pathology that often leads to death. Even if a person survives, it is very difficult for him to recover. Indeed, with a disease, the blood supply to the brain cells is blocked, which leads to an acute violation of cerebral circulation (stroke) and the death of tissues.
Thrombolysis in stroke helps prevent adverse effects. It quickly dissolves the blood clot and prevents necrosis of brain cells. In this case, you need to have time to administer the drug within 6 hours from the onset of signs of pathology.
The same thing happens with a heart muscle infarction. The disease also occurs due to clogging of the lumen of an artery with a thrombus. Often this is accompanied by thrombophlebitis.
To prevent myocardial tissue from perishing, thrombolytic treatment should be performed.
It allows you to eliminate acute coronary syndrome (ACS), reduce the area of muscle damage, maintain the function of the left ventricle, which pumps blood, as well as reduce the risk of complications and ensure stable heart function.
Indications for thrombolysis are various diseases of the heart and blood vessels, which are united by a phenomenon such as apoplexy. Similar diseases include:
- Myocardial infarction.
- TEL – thromboembolism of the lung.
- Blockage by a clot of deep veins, peripheral arteries or artificial prostheses located in the vascular lumens.
The need for thrombolytic treatment is determined by the attending doctor after examining the patient.
Doctors distinguish several factors in the presence of which the carrying out of thrombolytic therapy is impossible. If you prescribe treatment without paying attention to contraindications, there is a high risk of complications.
It is forbidden to do thrombolysis with such pathologies:
- High blood pressure.
- Allergy to medicines used in the treatment process.
- Vascular damage.
- Malignant tumors.
- Poor blood coagulability.
- Renal or liver failure.
- Diseases of the digestive organs.
- Diseases that can cause bleeding, for example, an aneurysm.
In addition to pathological conditions, it is not allowed to carry out thrombolytic therapy for women who are bearing a child, as well as for people taking anticoagulants, who have recently undergone surgery or received a skull injury in the last 2 weeks. Thrombolysis is also contraindicated in patients whose age is more than 75 years.
In medicine, there are a huge number of thrombolytic drugs. They are constantly being improved. At the moment, there are the following types of medications that differ in the nature of the effect:
- Natural enzymes. They are used only for systemic TLT. They help restore fibrinolysis, have a resolving effect on blood clots. But drugs affect the whole body, which is fraught with the occurrence of bleeding, the development of allergies. Therefore, they are used to a limited extent.
- Genetic engineering tools. Restore fibrinogen in the blood. Affect only a blood clot. They differ in instant dissolution in the blood, so they are used with caution.
- Advanced group drugs. They are characterized by the fact that they act selectively and for a long period.
- Combined medicines. They include several medical devices at once.
From all groups, several thrombolytics can be distinguished, which are most often used for thrombolysis. These include:
- “Streptokinase.” It has the lowest cost among all thrombolytic drugs. The disadvantage of its use is that a person often has intolerance to it, allergies and other unpleasant complications develop.
- Urokinase. Despite the fact that the price of this drug is higher than the previous one, its advantages are small. When using the medication, additional use of Heparin is required.
- “Tenecteplase.” On sale has another name – “Metalis”. It is injected, the use of “Heparin” and “Aspirin” is required. The drug can cause bleeding.
- “Anistreplaza.” Also has a high cost. The introduction of this tool can be carried out in a jet. When using it is not necessary to enter “Heparin” into a vein.
- Alteplaza. An expensive medication that has a highly effective effect. After its use, the survival of patients is much higher than with the use of other means. However, the drug has serious side effects.
- “Actylase.” The medication acts directly on a blood clot, does not cause a strong dilution of blood, which prevents the occurrence of hemorrhage.
In addition to thrombolytics during apoplexy, other drugs are used, for example, diuretics (“Fitolizin”), anticoagulants (“Heparin”), antiplatelet agents (“Aspirin”). Also, to eliminate symptoms, improve blood circulation, additional folk remedies are allowed to be used. In extreme cases, resort to surgical intervention.
The doctor is engaged in the appointment of surgical or drug treatment, taking into account the patient’s condition, the degree of development of the pathology, the presence of concomitant illness and other factors.
Thrombolysis can not only save the patient, but also cause adverse effects. These include:
- Bleeding. It occurs due to a deterioration in blood coagulability.
- Allergic reaction. It manifests itself in the form of skin rashes, accompanied by itching and swelling.
- Arrhythmia. Appears after restoration of coronary blood flow.
- Repeated manifestation of pain. With this complication, the administration of a narcotic analgesic into the vein is prescribed.
- Lowering blood pressure. To eliminate this side effect, it is enough to stop using thrombolytics.
The effectiveness of thrombolytic tablets and injections depends primarily on how timely the therapy was carried out. The greatest effect is achieved if the drug was administered no later than 5 hours after the onset of symptoms of pathology.
Unfortunately, it is far from always possible to carry out thrombolysis during this time. The problem lies in the fact that not all medical institutions have the opportunity to use the methodology in question.
How efficient the treatment has actually been can be found through examination. To do this, conduct magnetic resonance or computed tomography in situation of stroke or coronary angiography for heart muscle infarction. Diagnosis after thrombolysis shows the expansion of the lumen of the vessel and the destruction of the embolism.
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