Key result
IV thrombolysis causes no excess complications in recent NSTEMI, despite ~3.6-fold higher mortality.
Why the study?
Patients with AIS and recent or concurrent NSTEMI were excluded from pivotal thrombolysis trials, leaving clinical decisions poorly supported. Moreover, the recent endorsement of tenecteplase for stroke introduces considerations not addressed by the existing alteplase-based literature.
Does intravenous tenecteplase increase thrombolysis-related complications in patients with acute ischemic stroke and recent or concurrent NSTEMI?
Does intravenous tenecteplase increase thrombolysis-related complications in patients with acute ischemic stroke and recent or concurrent NSTEMI?
This narrative review highlights that historical contraindications to intravenous thrombolysis in acute ischemic stroke with recent MI stem largely from transmural STEMI complications, whereas registry data show no excess thrombolysis-related complications in patients with recent NSTEMI.
May support reconsidering NSTEMI as thrombolysis contraindication in stroke; leaves open prospective randomized confirmation.
Patients presenting with acute ischemic stroke (AIS) alongside a recent or concurrent non-ST-segment-elevation myocardial infarction (NSTEMI) occupy one of the least evidence-supported decision points in acute stroke care, excluded from every pivotal thrombolysis trial. The recent approval and guideline endorsement of tenecteplase-an agent separately licensed for myocardial infarction at twice the cerebral dose-adds a dimension the alteplase-derived literature does not address. This narrative review synthesizes the evidence on intravenous thrombolysis, specifically tenecteplase, in this setting and distinguishes infarct-related from treatment-related barriers to eligibility. Concomitant NSTEMI complicates approximately 1.6% of acute ischemic stroke hospitalizations and carries an adjusted 3.6-fold increase in in-hospital mortality. The historical contraindication derives from mechanisms-myocardial hemorrhage with free-wall rupture, postinfarction pericarditis with hemopericardium, and left ventricular thrombus embolization-that scale with transmurality and are therefore largely ST-segment-elevation myocardial infarction phenomena. Registry data from more than 40,000 thrombolyzed patients show no significant excess of thrombolysis-related complications with recent NSTEMI, and fatal ruptures cluster in subacute ST-segment-elevation myocardial infarction; the excess mortality is of similar magnitude without thrombolysis, marking a sicker patient rather than a more dangerous drug.
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Sharma et al. (2026) conducted a review in Acute ischemic stroke with recent or concurrent non-ST-segment-elevation myocardial infarction (NSTEMI). Intravenous tenecteplase vs. No thrombolysis or alteplase was evaluated on Thrombolysis-related complications and in-hospital mortality. Intravenous thrombolysis in >40,000 registry patients showed no significant excess of thrombolysis-related complications with recent NSTEMI, despite NSTEMI increasing mortality 3.6-fold.
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