Contraindications for Tenecteplase (TNK)
Tenecteplase (TNK) is absolutely contraindicated in patients with active internal bleeding, history of cerebrovascular accident, intracranial or intraspinal surgery or trauma within 2 months, intracranial neoplasm/arteriovenous malformation/aneurysm, known bleeding diathesis, and severe uncontrolled hypertension. 1
Absolute Contraindications
- Any prior intracranial hemorrhage (ICH) 2
- Known structural cerebral vascular lesion (e.g., arteriovenous malformation) 2
- Known malignant intracranial neoplasm (primary or metastatic) 2, 1
- Ischemic stroke within 3 months (except acute ischemic stroke within 4.5 hours in some guidelines) 2
- Suspected aortic dissection 2
- Active bleeding or bleeding diathesis (excluding menses) 2, 1
- Significant closed-head or facial trauma within 3 months 2
- Intracranial or intraspinal surgery within 2 months 2, 1
- Severe uncontrolled hypertension (unresponsive to emergency therapy) 2, 1
Relative Contraindications
- History of chronic, severe, poorly controlled hypertension 2
- Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg) 2
- History of prior ischemic stroke >3 months 2
- Dementia 2
- Known intracranial pathology not covered in absolute contraindications 2
- Traumatic or prolonged (>10 min) CPR 2
- Major surgery (<3 weeks) 2
- Recent (within 2-4 weeks) internal bleeding 2
- Noncompressible vascular punctures 2
- Pregnancy 2
- Active peptic ulcer 2
- Oral anticoagulant therapy 2
Clinical Considerations
Bleeding Risk
Tenecteplase can cause bleeding, including potentially fatal intracranial hemorrhage. The risk is heightened when used with other drugs that impair hemostasis 1. In clinical trials, TNK has demonstrated a favorable safety profile compared to other thrombolytics, with lower rates of non-cerebral bleeding complications 3.
Administration Precautions
- Avoid intramuscular injections and nonessential handling of the patient for the first few hours following treatment 1
- Perform arterial and venous punctures carefully and only as required 1
- Avoid internal jugular and subclavian venous punctures to minimize bleeding from noncompressible sites 1
- If arterial puncture is necessary, use an upper extremity vessel accessible to manual compression and apply pressure for at least 30 minutes 1
Special Populations
Elderly female patients with low body weight may have a lower risk of ICH with weight-optimized TNK compared to tPA 3. However, careful consideration of risks and benefits is essential in all high-risk populations.
Other Important Considerations
- TNK is incompatible with dextrose-containing solutions; flush lines with 0.9% sodium chloride before and after administration 1
- TNK can increase risk of thromboembolic events in patients with high likelihood of left heart thrombus (e.g., mitral stenosis, atrial fibrillation) 1
- Cholesterol embolism has been reported with thrombolytic agents 1
- Coronary thrombolysis may result in reperfusion arrhythmias; have anti-arrhythmic therapy available 1
The decision to use tenecteplase should be based on a careful risk-benefit analysis that considers the time from symptom onset, clinical and hemodynamic features, patient comorbidities, bleeding risk, presence of contraindications, and time delay to PCI when treating STEMI 2.