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Intravenous (IV) thrombolysis with the recombinant tissue plasminogen activator (rtPA) alteplase significantly increases the probability of excellent recovery, but dosage and administration remain unchanged since 1995. There is potentially substantial benefit from better IV thrombolytic agents. In other medical fields, newer plasminogen activators have replaced alteplase due to improved pharmacological characteristics. Data from previous small studies suggest that tenecteplase is potentially superior to IV alteplase, with respect to both safety and efficacy in stroke, as well as having much simpler administration, and lower cost. However substantially more data are required to establish the true risk-benefit profile compared with alteplase.

What is ATTEST 2?

ATTEST 2 is a prospective, randomised controlled multicentre parallel group trial comparing IV rtPA with IV tenecteplase in patients eligible for IV thrombolysis within guidelines (currently <4.5h after onset, with no upper age limit) based on non contrast CT imaging. The trial uses a PROBE (Prospective Randomised Open Blinded End-point) design.

An agent with superior risk:benefit ratio to alteplase would encourage treatment of a greater proportion of eligible patients than at present and strengthen the service reorganisation necessary to deliver acute care. Acute stroke treatment has established reperfusion as an achievable and clinically valuable treatment, but needs to move forward to optimise reperfusion strategies.