Is Percutaneous Coronary Intervention (PCI) recommended after tenecteplase (tissue plasminogen activator) administration if available?

PCI After Tenecteplase: Recommended Strategy

Yes, PCI is strongly recommended after tenecteplase administration, with immediate transfer to a PCI-capable center being the preferred approach rather than waiting to assess reperfusion success. 1

Evidence-Based Recommendation

The pharmacoinvasive strategy—immediate PCI following fibrinolytic therapy—has demonstrated superior outcomes compared to conservative management:

• The TRANSFER-AMI trial showed that immediate transfer for PCI within 6 hours of tenecteplase reduced the composite endpoint of death, reinfarction, recurrent ischemia, heart failure, and cardiogenic shock from 17.2% to 11.0% (RR 0.64, p=0.004). 1

• Transfer to a PCI center should be initiated immediately after fibrinolysis without waiting to determine whether reperfusion has occurred. 1

• The median time from tenecteplase to catheterization in successful pharmacoinvasive strategies was approximately 2.8 hours, with coronary angiography performed in 98.5% and PCI in 84.9% of patients. 1

Timing and Implementation

Rescue PCI (Immediate):

• Perform immediately if signs of failed reperfusion are present: persistent chest pain, <50% ST-segment resolution at 60-90 minutes, or hemodynamic/electrical instability. 1, 2, 3

Routine Early PCI (2-24 hours):

• For patients with successful fibrinolysis, angiography and PCI of the infarct-related artery should be performed between 2-24 hours after tenecteplase administration. 2
• This approach reduces mortality by 38% and reinfarction by 41% compared to delayed or ischemia-driven PCI. 1, 3

Critical Distinction: Facilitated vs. Pharmacoinvasive PCI

Important caveat: The FDA label warns against planned immediate PCI (facilitated PCI strategy where PCI is performed within 1-3 hours as the primary strategy). 4

• The ASSENT-4 PCI trial demonstrated that full-dose tenecteplase followed by planned PCI within 1-3 hours resulted in higher mortality (6.7% vs 4.9%), cardiogenic shock (6.3% vs 4.8%), and reinfarction (6.1% vs 3.7%) compared to primary PCI alone. 1, 4, 5

• The FDA states: "In patients with large ST segment elevation myocardial infarction, physicians should choose either thrombolysis or PCI as the primary treatment strategy for reperfusion." 4

Recommended Algorithm

If PCI is available within 90-120 minutes: Choose primary PCI over tenecteplase. 6, 2

If tenecteplase has already been administered:

1. Immediate transfer to PCI-capable center for all patients 6, 2
2. Assess reperfusion at 60-90 minutes (symptom relief, ST-segment resolution ≥50%, hemodynamic stability) 2, 3
3. If failed reperfusion: Proceed immediately with rescue PCI 1, 2, 3
4. If successful reperfusion: Perform angiography and PCI within 2-24 hours 1, 2, 3

Adjunctive Therapy During Transfer

• Continue aspirin and clopidogrel (or other P2Y12 inhibitor) 1, 2
• Maintain anticoagulation with unfractionated heparin or enoxaparin until revascularization 1, 2
• GP IIb/IIIa inhibitors may be administered at the PCI-capable hospital according to institutional protocols 1

High-Risk Features Warranting Aggressive Approach

Patients with any of the following should receive particularly urgent transfer: 1

• ≥2 mm ST-elevation in 2 anterior leads
• Systolic blood pressure <100 mmHg
• Heart rate >100 bpm
• Killip class II-III
• ≥2 mm ST-depression in anterior leads (suggesting posterior MI)
• Right ventricular involvement

Bleeding Risk Considerations

While the pharmacoinvasive strategy increases GUSTO mild bleeding (13.0% vs 9.0%), there is no significant difference in TIMI major/minor bleeding or GUSTO moderate/severe bleeding compared to standard treatment. 1