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Cardiovascular Emergency Pregnancy: Use only in life-threatening emergency — no adequate data in pregnancy; consult obstetric haematology urgently

Tenecteplase

Brand names: Metalyse

Adult dose

Dose: Weight-based single IV bolus: under 60 kg = 30 mg; 60–69 kg = 35 mg; 70–79 kg = 40 mg; 80–89 kg = 45 mg; 90 kg and above = 50 mg
Route: IV bolus
Frequency: Single dose
Max: 50 mg
Reconstitute with water for injection — use supplied syringe and device. Give over 5–10 seconds IV bolus. Start heparin/LMWH after bolus.

Paediatric dose

Dose: N/A N/A/kg
Route: N/A
Frequency: N/A
Max: N/A
Not licensed or established in paediatrics for STEMI; seek specialist paediatric cardiology opinion

Dose adjustments

Renal

No dose adjustment required

Hepatic

Use with caution in moderate-severe hepatic impairment — increased bleeding risk

Paediatric weight-based calculator

Not licensed or established in paediatrics for STEMI; seek specialist paediatric cardiology opinion

Clinical pearls

  • Advantages over alteplase: single weight-based IV bolus (alteplase requires 90-minute infusion) — faster administration, feasible pre-hospital or in non-cath-lab hospitals; longer half-life (20–24 min vs 4–8 min); greater fibrin specificity (14x vs alteplase)
  • STEMI use: indicated when primary PCI not available within 120 minutes of first medical contact and symptom onset within 12 hours — give bolus then transfer to PCI centre for rescue/pharmacoinvasive PCI
  • PE massive/submassive: tenecteplase 0.5 mg/kg (max 50 mg) single bolus is off-label but increasingly used in massive PE; alteplase remains first-line licensed agent
  • ASSENT-2 trial: tenecteplase non-inferior to alteplase for STEMI mortality with significantly less non-cerebral bleeding (26% vs 29%)
  • MHRA: licensed for STEMI only; PE use is off-label — document decision-making and discuss with cardiology/haematology
  • Post-lysis: give UFH 60 units/kg bolus (max 4,000 units) then infusion 12 units/kg/hour — or LMWH per local protocol

Contraindications

  • Previous haemorrhagic stroke
  • Ischaemic stroke within 6 months
  • Active internal bleeding
  • Intracranial neoplasm, AVM, or aneurysm
  • Aortic dissection
  • Recent major surgery or trauma within 3 months
  • Severe uncontrolled hypertension

Side effects

  • Bleeding (major and minor) — most common and serious
  • Intracranial haemorrhage (1–1.5%)
  • Reperfusion arrhythmias (accelerated idioventricular rhythm — usually benign, self-limiting)
  • Allergic reactions (rare — less than alteplase due to non-immunogenic profile)
  • Cholesterol embolisation

Interactions

  • Anticoagulants and antiplatelets (additive bleeding risk)
  • Glycoprotein IIb/IIIa inhibitors — avoid co-administration
  • Oral anticoagulants (relative contraindication to thrombolysis)

Monitoring

  • 12-lead ECG post-thrombolysis (ST resolution at 60–90 minutes — criterion for reperfusion)
  • Haemodynamics and clinical status
  • Signs of bleeding (including neurological — ICH)
  • APTT if UFH used concurrently
  • Transfer to catheterisation laboratory within 3–24 hours (pharmacoinvasive strategy)

Reference: BNFc; BNF 90; ESC STEMI Guidelines 2023; ASSENT-2 trial Lancet 1999;354(9180):716-722; NICE NG185. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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