The edition · Cardiology
Tenecteplase bleeding risk is set by three numbers you already have before you give it
A pooled analysis of 15,954 lysed STEMI patients turns age, weight and systolic pressure into a usable bleeding estimate; an amiodarone infusion is in Class II recall; and physiology beats the eye for non-culprit lesions.
The edition in brief
A pooled individual patient analysis from six tenecteplase trials — 15,954 patients with STEMI, 169 intracranial haemorrhages — identifies the risk as a product of age, dose, systolic pressure, weight and sex rather than a fixed background rate. Above 110 mmHg each 1 mmHg of systolic pressure added 2% relative risk (aOR 1.02, 95% CI 1.01-1.03), accelerating sharply beyond 160 mmHg. The age effect depended entirely on dose: risk rose about 1% per year of age at 30 mg and nearly 7% per year at 50 mg. Women had 49% higher odds (aOR 1.49, 95% CI 1.06-2.11) and each 5 kg less body weight added 16%. Both modifiable levers — lowering systolic pressure before the bolus, reducing dose in older patients — are available at the bedside. On regulation, Baxter's Nexterone (amiodarone) 360 mg/200 mL premixed bags are under an ongoing FDA Class II recall for manufacturing deviations. Class II means a reasonable probability of temporary or reversible harm. A nationwide English cohort of 7,836 patients followed for three years found CT-derived fractional flow reserve associated with myocardial infarction and cardiovascular death independent of stenosis severity, with 0.67 the optimal risk threshold and a 1.5% three-year event rate when it was normal. In ATTR cardiomyopathy, HELIOS-B showed vutrisiran's benefit was directionally consistent whether or not patients were already on tafamidis, with no significant interaction but numerically smaller effects on the stabiliser. The edition closes on AIR-STEMI: physiology-guided complete revascularisation cut events from 13.7% to 8.9% against angiography alone.
Before the tenecteplase bolus, three numbers set the bleeding risk
Lower the systolic pressure before giving tenecteplase and check the weight band carefully in older patients — both are modifiable, and both change bleeding risk substantially.
Premixed amiodarone bags under an ongoing Class II recall
Check with pharmacy whether your unit stocks Baxter premixed amiodarone bags and whether any stocked lots are affected; prescribing does not change.
CT-derived FFR predicts infarction and death beyond what the stenosis looks like
A normal stenosis-specific FFR-CT carries a 1.5% three-year risk of infarction or cardiovascular death — use it to reassure, and treat values at or below 0.7 as high risk.
Vutrisiran on top of tafamidis: consistent direction, smaller numbers
Treat vutrisiran added to tafamidis as mechanistically reasonable and unproven; this analysis rules out an obvious interaction, not much more.
Ask when the pain started, not when they arrived
Establish symptom onset by anchoring it to something the patient remembers, and record how you arrived at the time.
In multivessel STEMI, measure the non-culprit lesions rather than look at them
In multivessel STEMI, decide non-culprit lesions on a functional measurement rather than on appearance; it lowered events from 13.7% to 8.9% and reduced kidney injury and bleeding.
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