What is the clinical evidence from this study?

Study design: Cohort. Population: Acute Ischemic Stroke (n=133228). Intervention: Tenecteplase vs. Alteplase. Primary outcome: Door-to-needle time among patients who arrived directly to the reporting hospital (adjusted mean difference -3.13 minutes, 95% CI -3.84 to -2.42).

What question did this study set out to answer?

To compare door-to-needle and door-in-door-out times between tenecteplase-treated and alteplase-treated patients with acute ischemic stroke in US hospitals.

July 15, 2026JAMA Network OpenOpen Access

Tenecteplase vs Alteplase and Time to Treatment for Acute Ischemic Stroke

Q: What does this research mean for the field?

Tenecteplase is associated with significantly shorter door-to-needle and door-in-door-out times compared to alteplase in patients with acute ischemic stroke. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

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Key result

Tenecteplase is associated with a ~3-minute reduction in door-to-needle time versus alteplase in ischemic stroke.

adjusted mean difference -3.13 minutes
95% CI -3.84 to -2.42
n=133,228

Why the study?

Does tenecteplase improve door-to-needle and door-in-door-out times in adult patients with acute ischemic stroke compared to alteplase?

Population

133,228 adult patients with acute ischemic stroke who received intravenous thrombolysis, mean age 68.3…

Comparison

Tenecteplase vs Alteplase

Design

Cohort

Authors

SWSteven WarachThe University of Texas at Austin JWJeremy M. WeberDuke University BABrooke AlhantiDuke University

Discussion

Member takes

Implication

Tenecteplase provides modest but significant workflow time advantages over alteplase for acute ischemic stroke thrombolysis.

Key Points

To compare door-to-needle and door-in-door-out times between tenecteplase-treated and alteplase-treated patients with acute ischemic stroke in US hospitals.
Cohort study analyzing 133 228 adult patients with acute ischemic stroke who received intravenous thrombolysis across US hospitals in the Get With The Guidelines-Stroke registry between July 1, 2020, and June 30, 2022.
Evaluated 13 988 patients receiving tenecteplase and 119 240 receiving alteplase using generalized linear mixed models to assess door-to-needle and door-in-door-out intervals.
Mean (SD) door-to-needle time was significantly shorter with tenecteplase vs alteplase (47.0 [26.8] vs 52.7 [28.0] minutes; adjusted mean difference, -3.13 minutes; 95% CI, -3.84 to -2.42 minutes).
Door-to-needle time of 30 minutes or less was achieved more frequently with tenecteplase than alteplase (2955 of 9893 [29.9%] vs 14 781 of 72 539 [20.4%]; aOR, 1.34; 95% CI, 1.25 to 1.44), as were times of 45 minutes or less (58.3% vs 48.6%; aOR, 1.24; 95% CI, 1.17 to 1.32) and 60 minutes or less (77.5% vs 70.7%; aOR, 1.25; 95% CI, 1.17 to 1.33).
Among transferred patients eligible for mechanical thrombectomy, mean (SD) door-in-door-out times were shorter for tenecteplase vs alteplase (108.3 [31.6] vs 114.1 [32.0] minutes; adjusted mean difference, -5.94 minutes; 95% CI, -9.10 to -2.77 minutes).

Study Design

Type

Cohort (n=133,228)

Multicenter

Yes

Structured PICO

Does tenecteplase improve door-to-needle and door-in-door-out times in adult patients with acute ischemic stroke compared to alteplase?

Population

133,228 adult patients with acute ischemic stroke receiving intravenous thrombolysis across US hospitals.

Exposure

Tenecteplase

Comparator

Alteplase

Outcome

Door-to-needle time among patients who arrived directly to the reporting hospital and door-in-door-out time among those transferred after thrombolytic administrationsurrogate

Main Result

Mean Difference: -3.13 (95% CI -3.84–-2.42)

Absolute Event Rate: 47% vs 52.7%

Tenecteplase provides modest but significant workflow time advantages over alteplase for acute ischemic stroke thrombolysis.

Limitations

Voluntary registry program with limited generalizability
Nonrandomized, unblinded data
No external monitoring for data accuracy or completeness
Missing values for time metrics were not imputed
Findings largely reflect the experience of early adopter centers
Voluntary program with limited generalizability
No external monitoring for data accuracy
Missing values not imputed
Reflects early adopter centers

Cite This Study

Warach et al. (2026) conducted a cohort in Acute Ischemic Stroke (n=133,228). Tenecteplase vs. Alteplase was evaluated on Door-to-needle time among patients who arrived directly to the reporting hospital (adjusted mean difference -3.13 minutes, 95% CI -3.84 to -2.42). Tenecteplase reduced door-to-needle time by an adjusted mean difference of 3.13 minutes compared to alteplase in patients with acute ischemic stroke.

synapsesocial.com/papers/6a57234488b21df87548007a https://doi.org/10.1001/jamanetworkopen.2026.23260

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Tenecteplase vs Alteplase and Time to Treatment for Acute Ischemic Stroke

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Tenecteplase vs Alteplase and Time to Treatment for Acute Ischemic Stroke

Discussion

Member takes

Implication

Key Points

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Also Consider

Also Consider