Tenecteplase or Alteplase: What Is the Thrombolytic Agent of the Future?

Alteplase has been the thrombolytic of choice for acute ischaemic stroke for more than two decades. A thrombolytic which is easier to administer and with improved or comparable safety and efficacy is desirable. Tenecteplase has emerged as a potential successor, and its off-license use in acute ischaemic stroke has increased in recent years. We aimed to examine the evidence base for each drug and discuss their use in varying patient populations in acute ischaemic stroke.Several trials comparing tenecteplase and alteplase have reported very recently with the results of the ACT trial strengthening the argument in favour of non-inferiority of tenecteplase to alteplase. Ongoing trials such as ATTEST-2 are of interest, and trials such as TASTE and TEMPO-2 will shed further light on use of tenecteplase in specific populations.A single thrombolytic agent for all indications for thrombolysis in acute ischaemic stroke is desirable in streamlining workflows. Based on recent and upcoming trials, guidelines may soon recommend tenecteplase as a suitable alternative to alteplase. The use of tenecteplase in specific subgroups will depend on further recruitment to ongoing clinical trials.