What is the dosage of tenecteplase (TNK-tPA) for ST-elevation myocardial infarction (STEMI)?

Tenecteplase Dosing for ST-Elevation Myocardial Infarction

For patients with ST-elevation myocardial infarction (STEMI), tenecteplase should be administered as a single IV weight-based bolus according to the following dosing regimen: 30 mg for weight <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. 1, 2

Dosing Details and Administration

The weight-based dosing of tenecteplase for STEMI is as follows:

Patient Weight (kg)	TNKase (mg)	Volume to administer (mL)
< 60	30	6
60 to < 70	35	7
70 to < 80	40	8
80 to < 90	45	9
≥ 90	50	10

• Tenecteplase should be administered as a single IV bolus over 5 seconds 2
• Treatment should be initiated as soon as possible after symptom onset, with greatest benefit within the first 12 hours 1
• Tenecteplase is preferred over non-fibrin specific agents due to superior patency rates and less immunogenicity 1

Adjunctive Therapy

When administering tenecteplase for STEMI, the following adjunctive therapies should be given:

1. Antiplatelet therapy:

   • Aspirin: 162-325 mg loading dose, followed by 75-162 mg daily maintenance dose 1
   • Clopidogrel: 300 mg loading dose (for patients ≤75 years) or 75 mg (for patients >75 years), followed by 75 mg daily 1

2. Anticoagulation:

   • Enoxaparin (preferred): IV bolus followed by SC injection 1
   • OR Unfractionated heparin (UFH): 60 U/kg IV bolus (maximum 4000 U) followed by 12 U/kg/hr infusion (maximum 1000 U/hr), adjusted to maintain aPTT at 1.5-2.0 times control (approximately 50-70 seconds) 1

Special Considerations

• Elderly patients (>75 years): Consider half-dose tenecteplase to reduce the risk of intracranial hemorrhage 3
• Timing: Fibrinolysis should be considered if time from first medical contact to balloon inflation is >90 minutes for early presenters (<2 hours) with large infarcts and low bleeding risk, or >120 minutes for other patients 1
• Post-fibrinolysis care: Transfer to a PCI-capable center immediately after fibrinolysis is recommended 1
• Rescue PCI: Should be performed immediately if fibrinolysis fails (<50% ST-segment resolution at 60 minutes) 1

Contraindications

Absolute Contraindications 1:

• 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
• Severe uncontrolled hypertension (SBP >180 mm Hg or DBP >110 mm Hg)

Relative Contraindications 1:

• History of chronic, severe, poorly controlled hypertension
• Significant hypertension on presentation
• History of prior ischemic stroke >3 months
• Dementia
• Traumatic or prolonged CPR
• Major surgery (<3 weeks)
• Recent internal bleeding
• Noncompressible vascular punctures
• Pregnancy
• Active peptic ulcer
• Oral anticoagulant therapy

Clinical Efficacy

Tenecteplase has demonstrated equivalent efficacy to alteplase in mortality reduction but with fewer non-cerebral bleeding complications 4, 5. The ASSENT-2 trial showed similar 30-day mortality rates (approximately 6.2%) between tenecteplase and alteplase, with reduced bleeding complications in the tenecteplase group 5.