Introduction

    • Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy during a cardiac arrest; thrombolytic

    therapy is an option without PCI capability, followed by transfer to a PCI capable center.

    • Thrombolytic therapy is most effective when administered within 30 minutes of first medical contact, however, may be

    considered within 12 - 24 hours of symptom onset and ongoing ischemia or extensive ST elevation.

    • During ACS-Induced Cardiac Arrest, the goal for fibrinolysis is 30 minutes and reperfusion with PCI is preferred, however, if

    PCI is delayed, fibrinolytics therapy could be considered.

Clinical Detail

    Alteplase

    Tenecteplase

    MOA

    Initiates fibrinolysis by binding to fibrin in a thrombus

    and converts entrapped plasminogen to plasmin

    Promotes initiation of fibrinolysis by binding to fibrin

    and converting plasminogen to plasmin; similar to

    alteplase but more fibrin specific

    Dose

    Weight based:

    > 67kg: infuse 15mg IV bolus over 1-2 minute,

    followed by 50mg infusion over 30 minutes, then

    35mg over 1 hour (max total dose 100mg)

    <= 67kg: : infuse 15mg IV bolus over 1-2 minutes,

    followed by 0.75mg/kg infusion over 30 minutes,

    then 0.5mg/kg over 1 hour (max total dose 100mg)

    Weight based:

    < 60kg: 30mg

    >= 60 to < 70kg: 35mg

    >= 70 to < 80kg: 40mg

    >= 80 to < 90kg: 45mg

    >= 90kg: 50mg

    Administration

    • Bolus administered over 1 minute followed by

    infusion

    • Single bolus over 5 seconds

    PK/PD

    Duration: 1 hour after infusion terminated

    Distribution: approximates plasma volume

    Half-life elimination: 5 minutes

    Excretion: hepatic and plasma clearance

    Distribution: weight related

    Metabolism: hepatic

    Half-life elimination: biphasic; initial 20-24 min,

    terminal 90-130 min

    Excretion: plasma clearance

    Adverse Effects

    • Intracranial hemorrhage

Evidence

    Author,

    year

    Design/ sample

    size

    Intervention & Comparison

    Outcome

    Guillermin

    2016a

    Meta-analysis of

    RCT (n=18,208)

    • Tenecteplase 30-50mg vs alteplase

    80-100mg

    • Bleeding 4.8% in tenecteplase vs 5.8%

    alteplase (p=0.0002)

    • No difference in mortality at 30 days

    Llevadot

    2001

    Retrospective

    review (38

    studies)

    • Reteplase

    • Anoteplase

    • Tenecteplase

    • Tenecteplase and reteplase associated with

    accelerated infusion and more convenient by

    bolus administration

    • Administration of a less fibrin-specific agent

    may cause greater systemic coagulopathy

    with potential for more bleeding

    Boersma

    1996

    Retrospective

    review

    (n=50,246)

Conclusions

  • Evidence supports PCI is the first line option for management of patients requiring reperfusion during cardiac

    • arrest when a STEMI is suspected

  • Available evidence suggests tenecteplase and alteplase are appropriate fibrinolytic therapies when PCI is

    • unavailable

  • Tenecteplase is an alternative fibrinolytic therapy and has been evaluated safe and efficacious as a bolus

    • dose of 30-50mg

  • When alteplase is the only fibrinolytic therapy available, there is data to support bolus therapy +/- a weight

    • based infusion during cardiac arrest

  • Thrombolytic agents administered during CPR can improve the rate of survival but are associated with a risk of

    • severe bleeding

References

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