How to manage hypotension associated with Tenecteplase (TNK) administration?

Management of Hypotension Associated with Tenecteplase (TNK)

Hypotension associated with tenecteplase administration is uncommon compared to streptokinase, but when it occurs, immediately halt the infusion, position the patient supine with legs elevated, and consider atropine or intravenous volume expansion if needed. 1

Key Distinction: TNK vs. Streptokinase

• Tenecteplase (TNK) is NOT typically associated with hypotension, unlike streptokinase which commonly causes this complication 1
• TNK is a fibrin-specific agent with significantly lower rates of non-cerebral bleeding and better safety profile compared to non-fibrin-specific agents like streptokinase 1
• The hypotension management protocols in guidelines specifically reference streptokinase, not TNK 1

Immediate Management Protocol

If hypotension develops during TNK administration:

1. Stop the infusion immediately - Temporarily halt the TNK bolus if still being administered 1

2. Position the patient flat with legs elevated - This promotes venous return and improves preload 1

3. Assess for alternative causes - Consider:

   • Cardiogenic shock from the myocardial infarction itself 1
   • Right ventricular infarction (check right-sided ECG leads) 1
   • Bleeding complications (though major non-cerebral bleeds occur in only 4-13% of patients, and TNK has lower bleeding rates than alteplase) 1
   • Concurrent medications or allergic reactions 1

4. Pharmacologic intervention if needed:

   • Atropine for bradycardia-associated hypotension 1
   • Intravenous volume expansion with crystalloids for hypovolemia 1
   • Vasopressors (norepinephrine) if persistent hemodynamic instability despite volume resuscitation 2

Important Clinical Caveats

Do NOT routinely administer hydrocortisone - Prophylactic corticosteroids are not indicated for TNK administration 1

TNK can be safely resumed - Unlike streptokinase, which should never be readministered due to antibody formation and allergic reaction risk, TNK does not cause immunogenicity and theoretically could be continued after stabilization 1

Monitor for true complications:

• Severe hypotension requiring vasopressor support may indicate massive PE, cardiogenic shock, or bleeding 3, 2
• In one case series of PE patients receiving TNK, 18 patients with hypotension all recovered by discharge without specific intervention beyond standard supportive care 3

Post-TNK Monitoring Requirements

Monitor continuously for 60-180 minutes after administration: 1, 4

• ST-segment resolution (≥50% reduction indicates successful reperfusion) 1
• Hemodynamic stability (blood pressure, heart rate) 1, 4
• Cardiac rhythm 1
• Clinical symptom relief 1

Transfer to PCI-capable center - All patients receiving TNK should be transferred for early angiography (2-24 hours post-lysis if successful, immediately if failed reperfusion) 1, 4

Risk Factors and Prevention

Patients at higher risk for complications (not specifically hypotension):

• Advanced age, lower weight, female gender predict bleeding complications 1
• Severe uncontrolled hypertension (SBP >180 mmHg or DBP >110 mmHg) is an absolute contraindication 1

The weight-based dosing of TNK reduces complications: 1, 4

• <60 kg: 30 mg
• 60-69 kg: 35 mg
• 70-79 kg: 40 mg
• 80-89 kg: 45 mg
• ≥90 kg: 50 mg