Administration of Fibrinolysis Therapy
At remote nursing stations, the administration of fibrinolysis may be performed by a nurse under direct
physician supervision through Ontario Telemedicine Network (OTN) or indirect medical supervision
through a telephone order. Each nursing station, as part of their regional STEMI program, will need to
establish protocols with local physicians as well as in consultation with the nearest acute care hospital to
decide what is best suited to meet their local circumstances. Patients managed with fibrinolysis therapy
should receive adjuvant antiplatelet and anticoagulant therapy. Anticoagulants such as unfractionated
heparin (UFH), low molecular weight heparin (e.g. Enoxaparin) and factor Xa inhibitors (e.g.
Fondaparinux) inhibit thrombin and prevent clot formation. Currently, Enoxaparin, Heparin and
Fondaparinux are approved for use in STEMI in Canada. All three are approved for use with fibrinolysis.
Fondaparinux is not recommended for patients being transferred for pPCI. Enoxaparin requires dose
adjustment for patients at least 75 years of age and for patients with renal insufficiency (creatinine
clearance less than 30 ml per minute) when given with fibrinolysis therapy. Administration of
antiplatelet therapy following fibrinolysis has been shown to improve vessel patency once the clot has
been dissolved and prevent reinfarction. Aspirin (ASA) and Clopidogrel are approved in Canada to be
given with fibrinolysis therapy.