Tenecteplase Administration for STEMI

Introduction to Tenecteplase

• The American College of Cardiology recommends a weight-based dose of tenecteplase for STEMI: 30 mg for patients <60 kg, 35 mg for 60-69 kg, 40 mg for 70-79 kg, 45 mg for 80-89 kg, and 50 mg for ≥90 kg, administered as a single intravenous bolus over 5 seconds, with a strength of evidence based on high-quality randomized trials 1
• The FDA-approved dosing of tenecteplase for STEMI follows a weight-based protocol, as shown in the table:

Special Considerations

• For patients >75 years old, consider half-dosing to reduce the risk of intracranial hemorrhage, based on moderate-quality evidence from the STREAM trial 2
• For patients with Class 3 obesity (BMI ≥40), the standard weight-based dosing should be used with a ceiling dose of 50 mg, based on low-quality evidence 3
• Appropriate measurement of body weight is important to avoid underdosing, with a strength of evidence based on expert opinion 3

Administration and Monitoring

• Administration should be performed as a single IV bolus over 5 seconds, with initiation of treatment as soon as possible after symptom onset, based on high-quality evidence 1
• When administering tenecteplase for STEMI, give oral aspirin (150-325 mg) or IV aspirin (250-500 mg) if oral ingestion is not possible, add clopidogrel (300 mg loading dose if ≤75 years; 75 mg if >75 years), and provide anticoagulation until revascularization or for the duration of hospital stay (up to 8 days), based on moderate-quality evidence 4, 5
• Enoxaparin IV followed by SC (preferred over UFH) or weight-adjusted UFH should be used for anticoagulation, with a strength of evidence based on high-quality randomized trials 4, 5

Contraindications and Precautions

• Absolute contraindications to tenecteplase include any prior intracranial hemorrhage, known structural cerebral vascular lesion, known malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding or bleeding diathesis, significant closed-head or facial trauma within 3 months, intracranial or intraspinal surgery within 2 months, and severe uncontrolled hypertension, based on high-quality evidence 1
• Failure to reduce the dose in patients >75 years increases the risk of intracranial hemorrhage, with a strength of evidence based on moderate-quality evidence from the STREAM trial 2
• Carefully screen for absolute and relative contraindications before administering tenecteplase to minimize bleeding risks, based on expert opinion 1

Post-Fibrinolysis Care

• Initiate tenecteplase as soon as possible after STEMI diagnosis, as efficacy is time-dependent with greatest benefit within the first 12 hours after symptom onset, based on high-quality evidence 1
• Transfer patients to a PCI-capable center immediately after fibrinolysis for potential rescue PCI if needed, with a strength of evidence based on moderate-quality evidence 5, 2