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.