A 68-year-old woman complains of 45 minutes of crushing retrosternal chest pain. Her past history is significant for borderline diabetes and hypertension, but she has needed no treatment for either. She fell while jogging 3 months ago and required a total hip replacement. She appears anxious and acutely ill. Vital signs: heart rate, 120/min; respiratory rate, 18/min; blood pressure, 140/90 mm Hg; pulse oximetry, 98% on room air. Lung fields are clear; heart rhythm is regular with normal S1 and S2, loud S4, and no murmurs. You see no jugular venous distension. Her EKG shows sinus tachycardia with 2 mm ST elevation in leads II, III, and AVF. An absolute contraindication for use of a fibrinolytic agent is:
Rectal examination showing frankly bloody stool.
Recent use of aspirin for residual hip pain.
Nosebleed last week.
Hip surgery 3 months ago.
Allergy to peanuts.
Current approaches to fibrinolytic therapy of acute myocardial infarction (AMI) often refer to the first hour after onset of chest pain as the “golden hour,” when patients are likely to receive the maximum benefit from fibrinolysis. Absolute contraindications to fibrinolytic therapy include active internal bleeding, ischemia stroke within the prior 6 months, hemorrhagic stroke at any time, central nervous system neoplasm or aneurysm, diastolic blood pressure greater than 120 mm Hg after conservative therapy, pregnancy, major surgery within the prior 2 weeks, and known bleeding disorder.