Pulmonary Embolism
Stephen M. Cohn, Alan Lisbon, Stephen Heard in 50 Landmark Papers, 2021
For submassive high risk to massive PE, anticoagulation in addition to thrombolysis or thrombectomy may be indicated. Patients that have normal systolic blood pressure but show signs of right ventricular dysfunction may benefit from thrombolysis to avoid hemodynamic decompensation (Goldhaber). Thrombolytic agents such as Tenecteplase can provide rapid resolution of emboli. However, prior to fibrinolysis, patients must undergo extensive bleeding risk assessment as use of thrombolytics has significant bleeding complications. The PEITHO trial demonstrated great efficacy at preventing hemodynamic compromise but does increase the risk of intracranial hemorrhage and major bleeding events, especially for patients over the age of 75. There is some thought that half the standard dose of Tenecteplase may decrease bleeding risks; however, more research is needed (Meyer). For massive PE or patients that require aggressive intervention for PE but are at high risk for bleeding should be considered for catheter or surgical thrombectomy. Catheter-directed thrombolysis (CDT) has shown to be effective with low bleeding risks. However, randomized controlled trials are needed to compare directly with anticoagulation or systemic thrombolytics (Bloomer). In short, treatment beyond anticoagulation requires a thorough bleeding risk assessment and discussion with the patient regarding the risks and benefits of each procedure.
Acute coronary syndromes
Henry J. Woodford in Essential Geriatrics, 2022
If fibrinolysis is the better option, then this should be given within ten minutes of diagnosis, which can be pre-hospital. Contraindications to thrombolysis include prior intracerebral haemorrhage (ICH), ischaemic stroke in the last six months or a gastrointestinal bleed in the last month. A half-dose of tenecteplase should be considered for people aged over 75 due to lower risk of ICH.12 Anticoagulation and transfer to a PCI centre are often recommended following fibrinolysis. Early angiography (within 24 hours) or rescue PCI can be considered if there is no evidence of cardiac reperfusion (i.e. ST-segment resolution < 50% or clinical deterioration). Aspirin and clopidogrel are usually started around the same time.12
Practice Paper 10: Answers
Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar in Get ahead! Medicine, 2016
The other major class of thrombolytic drugs is the tissue-type plasminogen activators, which include tenecteplase, alteplase and reteplase. When tenecteplase is given, it is followed by an intravenous infusion of heparin to improve the chance of reperfusion. The main complications of thrombolysis are bleeding, reperfusion arrhythmia, allergic reaction and hypotension. Haemorrhagic stroke is perhaps the most serious complication of thrombolysis, and occurs in approximately 0.5% of cases.
Mechanical thrombectomy – is time still brain? The DAWN of a new era
Published in British Journal of Neurosurgery, 2018
Naveed Kamal, Neil Majmundar, Nitesh Damadora, Mohammad El-Ghanem, Rolla Nuoman, Irwin A. Keller, Steven Schonfeld, Igor Rybinnik, Gaurav Gupta, Sudipta Roychowdry, Fawaz Al-Mufti
Research in stroke has been reinvigorated, more so after the findings of the 5 landmark trials and the DAWN trial. The only approved intravenous thrombolytic in the US is alteplase, and its use is limited to the 3 hour time window. However, due to its limited efficacy in reperfusing large vessels and its short half-life, other thrombolytic agents have been investigated. Tenecteplase is a potential therapy for acute ischemic stroke, particularly because it is 15 times more specific for fibrin and has a longer half-life.59 This could lead to a reduced need to maintain an infusion of thrombolytics after the initial bolus. In addition, it is more resistant to plasminogen activator inhibition.60 This has led to its adoption as the preferred thrombolytic in acute ST-elevation myocardial infarction.61 A study by Parsons et al. found that tenecteplase given at a dose of .25 mg/kg was superior to alteplase in reperfusion and clinical outcomes.62 In addition, the NOR-TEST investigators announced that tenecteplase was associated with functional outcomes and safety similar to alteplase. Currently, several multicenter RCTs are underway comparing tenecteplase to alteplase (TEMPO-2, TIAS, TASTE, and EXTEND IA TNK).63
Organizing stroke systems in the field for patients with suspected large vessel occlusion acute stroke
Published in Expert Review of Cardiovascular Therapy, 2019
Mohammed A. Almekhlafi, Jessalyn K. Holodinsky, Michael D. Hill, Noreen Kamal, Mayank Goyal
The search for effective neuroprotective agents have been revived with the success of endovascular therapy, and some are undergoing testing, e.g., ESCAPE-NA1 trial (NCT02930018). If this approach is proven, such agents could justify minor delays encumbered to transfer patients to PSCs at the expense of tissue saved by administration of neuroprotective and thrombolytic agents prior to transfer to comprehensive centers. This will increase the PSCs experience in triaging, imaging, and managing these patients. Stroke systems of care may undergo major transformations to shorten the DTN (to 30 min or less [48]) and to accommodate for potential cytoprotective agent(s). Tenecteplase is positioned to replace alteplase as the thrombolytic agent of choice in acute ischemic stroke owing to its biological effect and ease of administration.
Endovascular treatment for ischemic stroke patients with and without atrial fibrillation, and the effects of adjunctive pharmacotherapy: a narrative review
Published in Expert Opinion on Pharmacotherapy, 2023
Muath Alobaida, Gregory Y H Lip, Deirdre A Lane, Dimitrios Sagris, Andrew Hill, Stephanie L Harrison
Although, alteplase remains the standard-of-care in IVT, tenecteplase may be a safe and effective alternative in patients undergoing both IVT and EVT[13]. One small randomized controlled trial including 202 patients with anterior and basilar ischemic stroke eligible for EVT showed higher recanalization rate, borderline association with better functional outcomes, and similar proportions of sICH in patient treated tenecteplase compared to alteplase[19]. Further, pooled subgroup analysis of two randomized controlled trials demonstrated higher rates of recanalization and functional outcomes in patient treated with tenecteplase compared to alteplase[20]. Accordingly, a meta-analysis of post-hoc pooled subgroup analysis of randomized controlled trials based on non-clinical primary outcomes showed better functional outcomes (modified Rankin Scale; mRS, 0–2) with tenecteplase compared to alteplase (OR: 2.09, 95% CI: 1.16–3.76)[13].
Related Knowledge Centers
- Asparagine
- Complementary DNA
- Enzyme
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- Glutamine
- Recombinant DNA
- Threonine
- Glycoprotein
- Thrombolysis
- Tissue-Type Plasminogen Activator