Emerg Med J 20:66-67 doi:10.1136/emj.20.1.66-b
  • Best evidence topic reports

Contraindications to thrombolysis in patients taking coumarins

  1. Andy Ashton, Senior Clinical Fellow,
  2. Stewart Teece, Clinical Research Fellow,
  3. K Mackway-Jones
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}


      A short cut review was carried out to establish what level of INR was a contraindication to thrombolysis in patients taking warfarins. Altogether 296 papers were found using the reported search, but none presented any evidence to answer the clinical question. More research is needed in this area and, in the mean time, local advice should be followed.

      Report by Andy Ashton, Senior Clinical Fellow
 Checked by Stewart Teece, Clinical Research Fellow

      Clinical scenario

      A 73 year old woman presents to the emergency department with chest pain. Her ECG shows left bundle branch block. She is taking warfarin for recurrent pulmonary emboli. Her INR is 2.7. While you look for her old notes to see if her left bundle branch block is new or not, you try to find out at what INR thrombolysis is contraindicated. Everyone gives you an answer, but the answers are all different. You wonder if there is any evidence to support any of the recommendations.

      Three part question

      In [a patient with myocardial infarction who is anticoagulated] at what [INR] is [thrombolysis contraindicated]?

      Search strategy

      Medline 1966–10/02 using the OVID interface. [exp urinary plasminogen activator OR exp thrombolytic therapy OR exp fibrinolysis OR exp tissue plasminogen activator OR exp fibrinolytic agents OR exp streptokinase OR thromboly$.af OR OR OR OR (tissue adj5 plasminogen adj5 activator).af OR fibrinoly$.af OR plasminogen] AND [exp International Normalized Ratio OR OR exp warfarin OR OR (International adj5 normalized adj5 ratio).af OR (International adj5 normalised adj5 ratio).af OR OR OR (British adj 5 standardised adj5 ratio).af OR (Brtitish adj5 standardized adj5 ratio).af OR ] AND [exp myocardial infarction OR (myocard$ adj5 infarct$).af OR (heart adj5 attack).af OR] LIMIT to human AND English.

      Search outcome

      Altogether 96 papers were found none of which were relevant to the three part question.


      Although various guidelines exist for thrombolysis in a patient who is anticoagulated, there does not seem to be any research evidence base for this.


      Local advice should be followed.

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      Among patients with minor TBI (GCS 13-15) getting CT scans ≥ 24 hours after injury, what proportion have a traumatic finding?


      0.5% - 43% response rate
      3% - 41% response rate
      10% - 16% response rate

      Related original article: PCT head imaging in patients with head injury who present after 24 h of injury: a retrospective cohort study