 Let's continue on and discuss direct factor 10a inhibitors. Direct factor 10a inhibitors bind to and they directly inhibit factor 10a. By inhibiting factor 10a, you are inhibiting the enzyme that converts pro thrombin or factor 2 to thrombin or factor 2a. We use this with treatment or prophylaxis of a deep vein thrombosis or pulmonary embolism. And we can also use it as a prophylaxis for strokes for patients that have AFib. Remember the concern with AFib is that the patient can actually have stasis of the blood inside the atrium that is fibrillating. And that can cause a murothrombus or clot to form that once we get back into a regular rhythm can break off and go to the brain as a stroke. Side effect of our direct factor 10a inhibitors is going to be once again bleeding. We're inhibiting coagulation, we can have bleeding. Two examples of our direct factor 10a inhibitors is going to be epixaban and raveroxaban. You can see that they have xa in their names which is also associated with the direct factor 10a to help you remember these names. Moving on, let's discuss thrombolytics. Thrombolytics come in and they directly or indirectly aid in a conversion of plasminogen to plasmin. And that plasmin then they come in and break up our thrombin and fibrin clots. So it actually breaks up what has already been there and destroys that clot. We can use this in a myocardial infarction early on if we need to break the clot up inside of the blood vessels. And we can also use it early on in an ischemic stroke. It is important though that this be an ischemic stroke and not a hemorrhagic stroke. If we give a thrombolytic to someone that has a hemorrhagic stroke we will make that bleeding significantly worse which will likely lead to our patient's death. So we have to rule out a hemorrhagic stroke before we can give thrombolytics. This can also be used in a severe pulmonary embolism to directly break up that clot. We will check lab values for PT and PTT with thrombolytics and you will see that both of them will increase. Side effects here are bleeding. Obviously like we said earlier we don't want to use this if there is an active bleed. So in a hemorrhagic stroke we are not going to use it. If we do have a ischemic stroke but we have other issues of bleeding elsewhere in the body that is going to be a contraindication to using a thrombolytic. Because while it can help with the clot in the brain it can make the bleeding elsewhere in the body worse. Another factor that can be a contraindication for thrombolytics is going to be if a patient has a previous intracranial bleed. Because we are concerned about that bleed reoccurring. If patients have had surgery or if they do have hypertension we are not going to use thrombolytics because that can exacerbate bleeding or potentially make bleeding occur. To reverse the function of thrombolytics we can use anti-fibrinolytics, platelet transfusions or factor corrections. Some examples of thrombolytics include out-to-place which is going to be the most common one you have heard of. Also known as TPA, retoplace, streptokinase and tenectoplace are also thrombolytics.