Review of tenecteplase (TNKase) in the treatment of acute myocardial infarction

Figures & data

Table 1 Reasons for preferring thrombolysis (TBL) to primary angioplasty (P-PCI)

TBL is immediately available everywhere

The time-delay to perform P-PCI exceeds 90 minutes in a large fraction of patients

P-PCI does not reduce mortality consistently, particularly vs pre-hospital TBL

TBL can be improved by new adjunctive treatments (clopidogrel and enoxaparin)

Table 2 Clinical studies with TNKase in STEMI

Trial (year)	Patients	Comparison	Main findings
ASSENT-2 (1999)	16,949	TNKase vs rt-PA	TNKase and rt-PA equivalent, ↓ major bleeding with TNKase
ASSENT-3 (2001)	6,095	ENOX vs ABX vs UFHa	ENOX and ABX better than UFH
ENTIRE-TIMI 23 (2002)	483	ENOX vs ABX vs UFHa	ENOX and ABX better than UFH, ↑ bleeding with ABX
ASSENT-3-PLUS (2003)	1,639	ENOX vs UFHa, pre-hospital delivery	↓ reinfarction with ENOX, ↑ stroke/intracranial bleed
CAPITAL-AMI (2005)	170	F-PCIc vs TNKasea	↓ residual ischemia with F-PCI
ASSENT-4 (2006)	1,667	F-PCIc vs P-PCIb	↑ death/ischemia/bleeding in the F-PCI group
WEST (2006)	304	TNKase vs F-PCIc vs P-PCI	TNKase and F-PCI comparable to P-PCI
GRACIA-2 (2007)	212	TNKased vs P-PCI	↑ reperfusion with TNKased Similar ventricular damage

^a All patients in the trial received TNKase.

^b P-PCI: Primary angioplasty.

^c F-PCI: Primary angioplasty, facilitated by TNKase.

^d TNKase followed by routine angioplasty within 3–12 hours (“pharmaco-invasive” approach).

Figure 1 ST-segment complete resolution after PCI and left ventricular ejection fraction in GRACIA-2.

P-PCI = Primary angioplasty.

Table 3 Reasons for using TNKase in STEMI patients

TNKase is the most fibrin-specific thrombolytic agent available

TNKase may be injected by single intravenous bolus in 5–10 seconds

TNKase is as effective as accelerated rt-PA, but with less major bleeding

Pre-hospital TNKase (with rescue/routine PCI) seems as effective as primary angioplasty

Table 4 How to use TNKase in STEMI patients

Bolus intravenous injection of TNKase over 5–10 seconds
TNKase dose according to body weight (BW)
30 mg if BW <60.0 kg
35 mg if BW between 60.0 and 69.9 kg
40 mg if BW between 70.0 and 79.9 kg
45 mg if BW between 80.0 and 89.9 kg
50 mg if BW ≥90.0 kg
Adjunctive anti-platelet therapy
Aspirin: 160–325 mg, followed by 75–162 mg per day, indefinitely
Clopidogrel: 75 mg per day (for at least 28 days if no stenting, 1 month
if using a bare metal stent, 1 year if using a drug eluting stent)
Initial clopidogrel dose: 300 mg if age ≤75 or if a stent is implanted
Adjunctive unfractionated heparin
Intravenous bolus: 60 U per kg (maximum 4000 U)
Intravenous infusion: 12 U per kg per hour (maximum 1000 U per hour)
Target activated partial thromboplastin time: 1.5–2.0 control
Treatment duration: minimum 48 hours
Adjunctive enoxaparin (only if serum creatinine <2.5 mg/dL in men, <2.0 in women):
Less than 75 years old: Intravenous bolus of 30 mg
Less than 75 years old: Subcutaneous injection of 1 mg/kg every 12 hours
At least 75 years old: No intravenous bolus
At least 75 years old: Subcutaneous injection of 0.75 mg/kg every 12 hours
If the creatinine clearance is <30 mL/min: subcutaneous injection every 24 hours
Treatment duration: for the duration of index hospitalization, up to 8 days
For patients undergoing PCI after TNKase
If on unfractionated heparin: additional boluses as needed
If on enoxaparin: no further anticoagulant if <8 hours from the subcutaneous injection
If on enoxaparin: additional intravenous bolus of 0.3 mg/kg if 8–12 hours
after the subcutaneous injection