(639) Alteplase vs Tenecteplase in Myocardial Infarction, Stroke, and Pulmonary Embolism in Cardiac Arrest

Introduction: Although tenecteplase is only FDA-approved for the management of acute myocardial infarction (MI), there is growing evidence to support its use in acute ischemic stroke and pulmonary embolism (PE) associated with cardiac arrest. At our institution, tenecteplase replaced alteplase as the preferred agent for these three indications in February 2022. The objective of this study was to evaluate if institutional utilization of tenecteplase is consistent with dosing guideline recommendations and to evaluate safety and efficacy outcomes associated with tenecteplase compared to alteplase.

Methods: A single-center retrospective chart review was conducted on patients who received tenecteplase between February 2022 and September 2022, as well as patients who received alteplase between June 2021 and January 2022. The primary endpoint was the percentage of patients receiving the appropriate dose based on the indication. Key secondary endpoints included rates of major and minor bleeding based on International Society of Thrombosis and Hemostasis criteria, intracranial hemorrhage, and inpatient mortality, as well as cost savings associated with the use of tenecteplase.

Results: Among 45 patients in the tenecteplase group and 41 patients in the alteplase group, 100% dosing adherence was achieved across all indications. The majority of patients received tenecteplase for stroke (78% tenecteplase vs 90% alteplase), followed by PE associated with cardiac arrest (15% tenecteplase vs 10% alteplase) and MI (7% tenecteplase vs 0% alteplase). Rates of major bleeding were higher in the alteplase group at 22% compared to 13% in the tenecteplase group (p=0.29), although rates of minor bleeding were similar among the two groups (2% each, p=0.95). Of those with major bleeding, the overall rates of intracranial hemorrhage were 17% in the alteplase group and 7% in the tenecteplase group (p=0.13). Inpatient mortality rates among the tenecteplase group were approximately 29% compared to 12% in the alteplase group (p=0.06). Total cost savings with the use of tenecteplase were approximately $101,000.

Conclusions: Our findings suggest that a formulary conversion from alteplase to tenecteplase for the management of these three indications can be safely implemented with additional cost savings benefits.