What is the recommended dose of tenecteplase (tissue plasminogen activator) for a patient with pulmonary embolism?

Tenecteplase Dosing for Pulmonary Embolism

For pulmonary embolism, tenecteplase should be administered as a weight-based single IV bolus using the same dosing regimen as for STEMI: 30 mg for <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

Dosing Algorithm

The weight-based dosing strategy is straightforward 1:

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

This is administered as a single bolus injection, which offers significant practical advantages over alteplase's 90-minute infusion protocol. 1

When to Use Thrombolysis in PE

Thrombolysis is primarily indicated for hemodynamically unstable patients with massive PE presenting with hypotension, shock, or cardiovascular collapse. 1, 2 The number needed to treat to prevent recurrent PE or death in massive PE is 10, making this a high-impact intervention in the right clinical context. 1

For intermediate-risk PE (hemodynamically stable but with RV dysfunction), the evidence is less definitive, though thrombolysis accelerates resolution of RV dysfunction and pulmonary artery pressure. 1, 3 Standard anticoagulation remains the primary treatment for this group unless clinical deterioration occurs. 2

Heparin Management Around Thrombolysis

Stop heparin before administering tenecteplase, then resume at maintenance dosing (1,300 IU/hour or 18 IU/kg/hour) after thrombolysis is complete. 1, 4 The target aPTT should be 1.5-2.5 times control (45-75 seconds). 1, 4, 2

Evidence Quality and Nuances

While the weight-based tenecteplase dosing comes from high-quality 2025 ACC/AHA guidelines, these doses are extrapolated from STEMI trials rather than PE-specific randomized controlled trials. 1 The landmark ASSENT-2 trial demonstrated tenecteplase was equivalent to alteplase for mortality but with reduced non-cerebral bleeding in acute MI patients. 1

Observational studies in PE patients using this same weight-based dosing have shown favorable outcomes with mortality rates of 2-8% and minimal bleeding complications. 5, 3, 6 One recent case report explored reduced dosing (0.37 mg/kg) in a high-risk elderly patient with successful outcomes, though this remains investigational. 7

Contraindications to Consider

Absolute contraindications include prior intracranial hemorrhage, known structural cerebral vascular lesions, malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding, significant head/facial trauma within 3 months, intracranial/intraspinal surgery within 2 months, and severe uncontrolled hypertension (SBP >180 or DBP >110 mmHg). 1

However, in life-threatening massive PE with hemodynamic collapse, contraindications should be ignored as the mortality risk from untreated PE exceeds bleeding risk. 2

Critical Pitfalls to Avoid

• Do not delay thrombolysis in hemodynamically unstable PE while pursuing additional diagnostic testing—bedside echocardiography showing RV dysfunction is sufficient. 4, 2
• Do not use reduced or "half-dose" tenecteplase outside of research protocols, as the standard weight-based dosing is established practice. 1
• Do not continue heparin during tenecteplase administration—this increases bleeding risk unnecessarily. 1, 4
• Do not forget to resume anticoagulation after thrombolysis, as recurrent thrombosis remains a significant risk. 1, 2