J Stroke.  2024 Sep;26(3):371-390. 10.5853/jos.2024.01284.

Ethnic Differences in the Safety and Efficacy of Tenecteplase Versus Alteplase for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

• Koh JH
• Lim CYJ
• Tan LTP
• Sia CH
• Poh KK
• Sharma VK
• Yeo LLL
• Ho AFW
• Wu T
• Kong WKF
• Tan BYQ

• KMID: 2559556
• DOI: http://doi.org/10.5853/jos.2024.01284

Abstract

Background and Purpose
Tenecteplase is a thrombolytic agent with pharmacological advantages over alteplase and has been shown to be noninferior to alteplase for acute ischemic stroke in randomized trials. However, evidence pertaining to the safety and efficacy of tenecteplase in patients from different ethnic groups is lacking. The aim of this systematic review and metaanalysis was to investigate ethnicity-specific differences in the safety and efficacy of tenecteplase versus alteplase in patients with acute ischemic stroke.
Methods
Following an International Prospective Register of Systematic Reviews (PROSPERO)- registered protocol (CRD42023475038), three authors conducted a systematic review of the PubMed/MEDLINE, Embase, Cochrane Library, and CINAHL databases for articles comparing the use of tenecteplase with any thrombolytic agent in patients with acute ischemic stroke up to November 20, 2023. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Two independent authors extracted data onto a standardized data collection sheet. A pairwise meta-analysis was conducted in risk ratios (RR).
Results
From 34 studies (59,601 participants), the rate of complete recanalization was significantly higher (P<0.01) in Asian (RR: 1.91, 95% confidence interval [CI]: 1.30 to 2.80) versus Caucasian patients (RR: 0.99, 95% CI: 0.87 to 1.14). However, Asian patients (RR: 1.18, 95% CI: 0.87 to 1.62) had significantly higher (P=0.01) rates of mortality compared with Caucasian patients (RR: 1.10, 95% CI: 1.00 to 1.22). Caucasian patients were also more likely to attain a modified Rankin Scale (mRS) score of 0 to 2 at follow-up (RR: 1.14, 95% CI, 1.10 to 1.19) compared with Asian (RR: 1.00, 95% CI, 0.95 to 1.05) patients. There was no significant difference in the rate of symptomatic intracranial hemorrhage (P=0.20) and any intracranial hemorrhage (P=0.83) between Asian and Caucasian patients.
Conclusion
Tenecteplase was associated with significantly higher rates of complete recanalization in Asian patients compared with Caucasian patients. However, tenecteplase was associated with higher rates of mortality and lower rates of mRS 0 to 2 in Asian patients compared with Caucasian patients. It may be beneficial to study the variations in response to tenecteplase among patients of different ethnic groups in large prospective cohort studies.

Keyword

Thrombolysis; Ischemic stroke; Acute stroke; Brain

Figure

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  Figure 1. PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) flow diagram for included articles.

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  Figure 2. Forest plot for mRS score of 0 to 2 at final follow-up. mRS, modified Rankin Scale; RR, risk ratio; CI, confidence interval.

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  Figure 3. Forest plot for mRS score of 0 to 1 at final follow-up. mRS, modified Rankin Scale; RR, risk ratio; CI, confidence interval.

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  Figure 4. Forest plot for complete recanalization. RR, risk ratio; CI, confidence interval.

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  Figure 5. Forest plot for mortality. RR, risk ratio; CI, confidence interval.

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  Figure 6. Forest plot for sICH. RR, risk ratio; CI, confidence interval; sICH, symptomatic intracranial hemorrhage.

Reference

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