Brief Report

Coagulation and Fibrinolytic Activity of Tenecteplase

and Alteplase in Acute Ischemic Stroke
Xuya Huang, MRCP; Fiona Catherine Moreton, MRCP; Dheeraj Kalladka, MRCP;
Bharath Kumar Cheripelli, MRCP; Rachael MacIsaac, PhD; R. Campbell Tait, MBChB;
Keith W. Muir, MD

Background and Purpose—We compared the fibrinolytic activity of tenecteplase and alteplase in patients with acute
ischemic stroke, and explored the association between hypofibrinogenaemia and intracerebral hemorrhage.
Methods—Venous blood samples from a subgroup of participants in the Alteplase–Tenecteplase Trial Evaluation for Stroke
Thrombolysis (ATTEST) study were obtained at pretreatment, 3 to 12 hours, and 24±3 hours post-intravenous thrombolysis
for analyses of plasminogen, plasminogen activator inhibitor-1, d-dimer, factor V, fibrinogen, and fibrin(ogen) degradation
products, in addition to routine coagulation assays. Related sample Wilcoxon signed-rank tests were used to test the
within-group changes, and independent Mann–Whitney tests for between-group differences.
Results—Thirty patients were included (alteplase=14 and tenecteplase=16) with similar baseline demographics. Compared
with baseline, alteplase caused significant hypofibrinogenaemia (P=0.002), prolonged prothrombin time (P=0.011),
hypoplasminogenaemia (P=0.001), and lower factor V (P=0.002) at 3 to 12 hours after administration with persistent
hypofibrinogenaemia at 24 hours (P=0.011), whereas only minor hypoplasminogenaemia (P=0.029) was seen in the
tenecteplase group. Tenecteplase consumed less plasminogen (P<0.001) and fibrinogen (P=0.002) compared with
alteplase.
Conclusions—In patients with acute ischemic stroke, alteplase 0.9 mg/kg caused significant disruption of the fibrinolytic
system, whereas tenecteplase 0.25 mg/kg did not, consistent with the trend toward lower intracerebral hemorrhage
incidence with tenecteplase in the ATTEST study.
Clinical Trial Registration—URL: [Link] Unique identifier: NCT01472926.   
(Stroke. 2015;46:00-00. DOI: 10.1161/STROKEAHA.115.011290.)
Key Words: alteplase ◼ cerebral hemorrhage ◼ factor V ◼ prothrombin time ◼ stroke ◼ tenecteplase ◼ thrombolysis

I ntravenous thrombolysis with alteplase in acute ischemic

stroke improves clinical outcome, but is associated with
an absolute risk of fatal intracerebral hemorrhage (ICH) of
to receive a standard alteplase regime (0.9 mg/kg) or 0.25 mg/kg
tenecteplase. This substudy was initiated partway through the main
trial. All trial participants were approached after it commenced.
Venous blood samples were collected into citrate (final concentra-
around 2.7%, ≈7-fold greater odds compared with placebo tion 0.109 mol/L, Greiner Bio-One, Austria) at baseline (prethrom-
(odds ratio [95% confidence interval], 7.14 [3.98–12.79]).1 In bolysis; time point [TP] 1), 3 to 12 hours (TP2), and 24±3 hours
2 phase 2 trials in acute ischemic stroke,2,3 tenecteplase was (TP3) after the initiation of thrombolysis. Plasma was harvested by
associated with a trend toward fewer ICH complications. centrifugation immediately after sampling and stored at −80°C until
As a substudy of the Alteplase–Tenecteplase Trial analysis. We measured prothrombin time, activated partial thrombo-
plastin time (APTT), fibrinogen, fibrin(ogen) degradation products,
Evaluation for Stroke Thrombolysis (ATTEST) study, we plasminogen, d-dimer, factor V (FV), plasminogen activator inhibi-
compared the effects of the 2 agents on coagulation and tor-1 activity, and prothrombin fragment 1+2 (F1+2) at 3 TPs, respec-
the fibrinolytic system, and explored potential associations tively (assay methods are shown in detail in Table I in the online-only
with ICH. Data Supplement).

Methods Statistical Analysis

The study protocol of ATTEST has been detailed elsewhere.3 Eligible Baseline values were expressed as mean±SD, changes at TP2 and
thrombolysis candidates within 4.5 hours of onset were randomized TP3 as mean±SD percent change from baseline. We used related

Received August 26, 2015; final revision received August 26, 2015; accepted September 9, 2015.
From the Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (X.H.,
F.C.M., D.K., B.K.C., K.W.M.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.); and
Haematology Department, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom (R.C.T.).
The online-only Data Supplement is available with this article at [Link]
115.011290/-/DC1.
Correspondence to Keith Muir, MD, Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow
G51 4TF, Scotland, United Kingdom. E-mail [Link]@[Link]
© 2015 American Heart Association, Inc.
Stroke is available at [Link] DOI: 10.1161/STROKEAHA.115.011290

1 Libraries - [Link] on October 30, 2015

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2  Stroke  December 2015

sample Wilcoxon signed-rank tests to examine the within-groups dif- hemorrhagic infarction type2; the other patient’s fibrinogen
ferences (TP2 versus TP1 and TP3 versus TP1), using a Bonferroni rose to 1.4 g/L at TP3, who had subarachnoid hemorrhage.
correction to yield a significance level of P<0.025. Between-group
effects were explored with independent Mann–Whitney test. An uni-
Binary logistic regression found no association between ICH
variate binary logistic regression model was used to explore any as- and the change of fibrinogen between TP2 and TP1 (P=0.37).
sociation between the change of fibrinogen and ICH.
Discussion
Results Tenecteplase has 15-fold higher fibrin specificity than
Of 104 participants in the main ATTEST trial, 30 participated alteplase.6 High fibrin affinity should translate into greater
in this substudy (alteplase=14 and tenecteplase=16; Figure I potency for thrombolysis, while preserving the integrity of
in the online-only Data Supplement). Key baseline character- systemic coagulation.7 Acute ischemic stroke trials suggest
istics were similar between groups (Table). that tenecteplase may be associated with lower ICH risk with
similar or superior recanalization compared with alteplase.2,3
Effects on Coagulation and Fibrinolysis In this sample, alteplase caused significant fibrinogen deple-
Alteplase was associated with prolongation of prothrombin tion and consumption of plasminogen, and degradation of fac-
time (P=0.005), reduced fibrinogen (P=0.011) and plasmino- tor V, whereas tenecteplase did not.
gen (P<0.001), elevated fibrin(ogen) degradation products Early degradation of fibrinogen is associated with the
(P=0.002) 24-hour post-thrombolysis, a transient drop of fac- occurrence of ICH. Matosevic et al8 reported that within
tor V (P=0.002), and increase of d-dimer (P=0.003) at TP2 6-hours post-thrombolysis, a decrease of ≥2g/L in fibrino-
(Figure; Table II in the online-only Data Supplement). In con- gen level was an independent predictor for bleeding of all
trast, tenecteplase resulted only in elevation of fibrin(ogen) kinds. Significant hypofibrinogaemia (a decrease of 2 g/L
degradation products (P=0.009), d-dimer (P=0.008) ≤24 hours or 50% from baseline) occurs in about one fifth of those
and transient reduction of plasminogen (P=0.029) at TP2. receiving intravenous alteplase, whereas a tenecteplase dose
Compared with tenecteplase, alteplase induced greater escalation study9 showed no severe hypofibrinogenaemia
change of prothrombin time (P=0.037), fibrinogen (P=0.002), (fibrinogen <1 g/dL) in any dose (0.1–0.5 mg/kg) tested.
plasminogen (P<0.001), and factor V (P=0.002) at TP2, with Similarly, in our sample, tenecteplase treatment did not
sustained differences in prothrombin time (P=0.031), fibrino- cause hypofibrinogenaemia using either of these criteria.
gen (P=0.011), and plasminogen (P=0.001) at 24 hours. We could not replicate an association between hypofibrino-
genaemia and ICH, probably because of the small sample.
Association Between ICH and Depletion of Limitations of our study include small sample size, variable
Fibrinogen time of sampling at TP2, and the low incidence of serious ICH
Six patients had hemorrhage post-thrombolysis (4 with alteplase (none having parenchymal hemorrhage or symptomatic clini-
and 2 with tenecteplase), 4 classified as hemorrhagic infarc- cal deterioration attributable to hemorrhage). Nonetheless, we
tion4 1, 1 as hemorrhagic infarction type2, and 1 had a small found significant changes in coagulation and fibrinolysis after
subarachnoid hemorrhage. None was considered symptomatic intravenous alteplase consistent with the literature, and minimal
using either the second European Co-Operative Acute Stroke disruption with tenecteplase, consistent with a potentially better
Study (ECASS 2) or the Safe Implementation of Thrombolysis safety profile for tenecteplase, with retained fibrinolytic efficacy.
for Stroke - Monitoring Study (SITS-MOST) criteria.5
Fibrinogen level dropped below 1 g/L at TP2 in 2 patients, Conclusions
both of whom received alteplase (2/30, 14%). This low In acute ischemic stroke, tenecteplase caused significantly less
level persisted at TP3 in 1, whose follow-up CT revealed disruption to the coagulation and fibrinolytic systems compared

Table. Key Demographic and Stroke Characteristics of the 30 Patients

Alteplase, n=14 Tenecteplase, n=16 P Value
Age, y (mean±SD) 70±12 69±15 0.95
Male (n, %) 10 (71%) 10 (63%) 0.71
OTT min (mean±SD) 187±52 181±47 0.75
Baseline NIHSS (median, IQR) 10 (6–15) 11 (8–17) 0.58
Cardioembolic stroke (n, %) 8 (57%) 8 (50%) 0.7
Baseline vessel occlusion (n, %) 9 (64%) 8 (50%) 0.34
Large vessel occlusion, ICA, M1, (n, %) 6 (43%) 6 (38%) 0.7
Sampling time for TP2, h (median, IQR; range) 5.3 (4.8–10.1; 3.7–11.6) 4.4 (3.9–11.8; 3–12.1) 0.27
Sampling time for TP3, h (median, IQR; range) 23.8 (23.1–24.6; 20.9–25.5) 23.9 (23.5–24.6; 21.2–25.5) 0.62
Diurnal sampling for TP2* (n, %) 1 (7%) 5 (31%) 0.3
ICA indicates internal carotid artery; IQR, interquartile range; M1, middle cerebral artery M1 segment; NIHSS, National Institutes of
Health Stroke Scale; OTT, onset to treatment time; TP, time point; TP2, 2–12 h post-thrombolysis; and TP3, 24±3 h post-thrombolysis.
*Sampling time between 7 and 9 am. Frequencies were compared using χ2 test and Fisher test; mean or median values were
compared using independent t test and Mann–Whitney U test, respectively.

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 Huang et al   Fibrinolytic Activity of Tenecteplase and Alteplase    3

Figure. The changes of coagulation and fibrinolytic variables in alteplase- and tenecteplase-treated stroke patients from baseline to 24-hour
post-thrombolysis. APTT indicates activated partial thromboplastin time; F1+2, prothrombin fragment 1+2; FDP, fibrin(ogen) degradation
products; PAI-1, plasminogen activator inhibitor-1; and PT, prothrombin time. *Statistical significant difference within or between groups.

with alteplase. This finding was consistent with the trend toward Conference 2013 on acute stroke treatment. Boehringer Ingelheim
reduced incidence of ICH observed in the ATTEST trial. manufactures both drugs used in this trial. The other authors report
no conflicts.

Acknowledgments
We thank Prof. Gary Ford and Dr M.J. MacLeod from the Trial
References
1. Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, et al;
Steering Committee; Prof. Kennedy R. Lees, Drs Mark Parsons, and
Stroke Thrombolysis Trialists’ Collaborative Group. Effect of treatment
Christopher Weir from Data Safety Monitoring Committee; and Prof. delay, age, and stroke severity on the effects of intravenous thrombolysis
Michael Hill and Dr Andrew Demchuk from External adjudicators. with alteplase for acute ischaemic stroke: a meta-analysis of individual
patient data from randomised trials. Lancet. 2014;384:1929–1935. doi:
10.1016/S0140-6736(14)60584-5.
Sources of Funding 2. Parsons M, Spratt N, Bivard A, Campbell B, Chung K, Miteff F, et
This study was supported by the Stroke Association (TSA2010/04) al. A randomized trial of tenecteplase versus alteplase for acute isch-
and National Health Service Endowment Fund (National Health emic stroke. N Engl J Med. 2012;366:1099–1107. doi: 10.1056/
Service Greater Glasgow & Clyde). NEJMoa1109842.
3. Huang X, Cheripelli BK, Lloyd SM, Kalladka D, Moreton FC, Siddiqui
A, et al. Alteplase versus tenecteplase for thrombolysis after isch-
Disclosures aemic stroke (ATTEST): a phase 2, randomised, open-label, blinded
Dr Muir received a personal fee from Boehringer Ingelheim for endpoint study. Lancet Neurol. 2015;14:368–376. doi: 10.1016/
speaking at a sponsored satellite meeting at European Stroke S1474-4422(15)70017-7.

Downloaded from [Link] at CMU Libraries - [Link] on October 30, 2015

4  Stroke  December 2015

4. Hacke W, Kaste M, Fieschi C, von Kummer R, Davalos A, Meier D, 7. Sakharov DV, Barrertt-Bergshoeff M, Hekkenberg RT, Rijken DC.
et al. Randomised double-blind placebo-controlled trial of thrombolytic Fibrin-specificity of a plasminogen activator affects the effi-
therapy with intravenous alteplase in acute ischaemic stroke (ECASS ciency of fibrinolysis and responsiveness to ultrasound: com-
II). Second European-Australasian Acute Stroke Study Investigators. parison of nine plasminogen activators in vitro. Thromb Haemost.
Lancet. 1998;352:1245–1251. 1999;81:605–612.
5. Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W. 8. Matosevic B, Knoflach M, Werner P, Pechlaner R, Zangerle A, Ruecker
Thrombolysis with alteplase for acute ischaemic stroke in the safe M, et al. Fibrinogen degradation coagulopathy and bleeding complica-
implementation of thrombolysis in stroke-monitoring study (sits-most): tions after stroke thrombolysis. Neurology. 2013;80:1216–1224. doi:
An observational study. Lancet. 2007;369:275–282. 10.1212/WNL.0b013e3182897015.
6. Tanswell P, Modi N, Combs D, Danays T. Pharmacokinetics and phar- 9. Haley EC Jr, Lyden PD, Johnston KC, Hemmen TM; TNK in Stroke
macodynamics of tenecteplase in fibrinolytic therapy of acute myo- Investigators. A pilot dose-escalation safety study of tenecteplase in
cardial infarction. Clin Pharmacokinet. 2002;41:1229–1245. doi: acute ischemic stroke. Stroke. 2005;36:607–612. doi: 10.1161/01.
10.2165/00003088-200241150-00001. STR.0000154872.73240.e9.

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 Coagulation and Fibrinolytic Activity of Tenecteplase and Alteplase in Acute Ischemic
Stroke
Xuya Huang, Fiona Catherine Moreton, Dheeraj Kalladka, Bharath Kumar Cheripelli, Rachael
MacIsaac, R. Campbell Tait and Keith W. Muir

Stroke. published online October 29, 2015;

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