Intravenous Tenecteplase for Acute Ischemic Stroke in Patients With Recent or Concurrent Non–ST-Segment–Elevation Myocardial Infarction

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.