Articles

Tenecteplase versus alteplase in acute ischaemic

cerebrovascular events (TRACE-2): a phase 3, multicentre,
open-label, randomised controlled, non-inferiority trial
Yongjun Wang, Shuya Li, Yuesong Pan, Hao Li, Mark W Parsons, Bruce C V Campbell, Lee H Schwamm, Marc Fisher, Fengyuan Che, Hongguo Dai,
Deyang Li, Runhui Li, Junhai Wang, Yilong Wang, Xingquan Zhao, Zixiao Li, Huaguang Zheng, Yunyun Xiong, Xia Meng, for the TRACE-2
Investigators*

Summary
Background There is increasing interest in replacing alteplase with tenecteplase as the preferred thrombolytic Lancet 2023; 401: 645–54
treatment for patients with acute ischaemic stroke. We aimed to establish the non-inferiority of tenecteplase to Published Online
alteplase for these patients. February 9, 2023
https://doi.org/10.1016/
S0140-6736(22)02600-9
Methods In this multicentre, prospective, open-label, blinded-endpoint, randomised controlled, non-inferiority trial,
This online publication has been
adults with an acute ischaemic stroke who were eligible for standard intravenous thrombolysis but ineligible for corrected. The corrected version
endovascular thrombectomy were enrolled from 53 centres in China and randomly assigned (1:1) to receive first appeared at thelancet.com
intravenous tenecteplase (0·25 mg/kg, maximum dose of 25 mg) or intravenous alteplase (0·9 mg/kg, maximum on March 30, 2023
dose of 90 mg). Participants had to be able to receive treatment within 4·5 h of stroke, have a modified Rankin Scale See Comment page 618
(mRS) score of no more than 1 before enrolment, and have a National Institutes of Health Stroke Scale score of 5–25. *Investigators listed in the
Patients and treating clinicians were not masked to group assignment; clinicians evaluating outcomes were masked appendix

to treatment type. The primary efficacy outcome was the proportion of participants who had a mRS score of 0–1 at Department of Neurology and
Department of Clinical Trial
90 days, assessed in the modified intention-to-treat population (all randomly assigned participants who received the Center, Beijing Tiantan
allocated thrombolytic), with a non-inferiority margin of 0·937 for the risk ratio (RR). The primary safety outcome Hospital, Capital Medical
was symptomatic intracranial haemorrhage within 36 h, assessed in all participants who received study drug and University, Beijing, China
had a safety assessment available. The trial is registered with ClinicalTrials.gov, NCT04797013, and has been (Prof Yo Wang MD, S Li MD,
Prof Y Pan PhD, Prof H Li PhD,
completed. Prof Yi Wang MD,
Prof X Zhao MD, Prof Z Li MD,
Findings Between June 12, 2021, and May 29, 2022, 1430 participants were enrolled and randomly assigned to H Zheng MD, Y Xiong MD,
tenecteplase (n=716) or alteplase (n=714). Six patients assigned to tenecteplase and seven to alteplase did not receive X Meng MD); China National
Clinical Research Center for
study product, and five participants in the tenecteplase group and 11 in the alteplase group were lost to follow-up at Neurological Diseases, Beijing,
90 days. The primary outcome in the modified intention-to-treat population occurred in 439 (62%) of 705 in the China (Prof Yo Wang, S Li,
tenecteplase group versus 405 (58%) of 696 in the alteplase group (RR 1·07, 95% CI 0·98–1·16). The lower limit of Prof Y Pan, Prof H Li,
the RR’s 95% CI was greater than the non-inferiority margin. Symptomatic intracranial haemorrhage within 36 h was Prof Yi Wang, Prof X Zhao,
Prof Z Li, H Zheng, Y Xiong,
observed in 15 (2%) of 711 in the tenecteplase group and 13 (2%) of 706 in the alteplase group (RR 1·18, 95% CI X Meng); Department of
0·56–2·50). Mortality within 90 days occurred in 46 (7%) individuals in the tenecteplase group versus 35 (5%) in the Neurology, Liverpool Hospital,
alteplase group (RR 1·31, 95% CI 0·86–2·01). University of New South
Wales, Sydney, NSW, Australia
(Prof M W Parsons PhD); South
Interpretation Tenecteplase was non-inferior to alteplase in people with ischaemic stroke who were eligible for Western Sydney Clinical
standard intravenous thrombolytic but ineligible for or refused endovascular thrombectomy. School, Sydney, NSW, Australia
(Prof M W Parsons); The Ingham
Funding National Science and Technology Major Project, Chinese Academy of Medical Sciences Innovation Fund for Institute for Applied Medical
Research, Sydney, NSW,
Medical Sciences, National Natural Science Foundation of China, and China Shijiazhuang Pharmaceutical Company Australia (Prof M W Parsons);
Recomgen Pharmaceutical (Guangzhou). Department of Medicine and
Neurology, Melbourne
Brain Centre at the
Copyright © 2023 Published by Elsevier Ltd. All rights reserved.
Royal Melbourne Hospital,
Melbourne, VIC, Australia
Introduction injected over the course of an hour).5 The recent (Prof B C V Campbell PhD);
Intravenous alteplase has been recommended as a Tenecteplase In Patients with Acute Ischaemic Stroke Florey Institute of
Neuroscience and Mental
standard therapy for eligible people who have had acute (AcT) trial (NCT03889249), a registry linked trial, showed
Health, University of
ischaemic strokes.1–3 Tenecteplase, which differs from that tenecteplase (0·25 mg/kg) was non-inferior to Melbourne, Parkville, VIC,
alteplase in three amino acids, has a well characterised alteplase (0·9 mg/kg) for excellent functional outcomes Australia (Prof B C V Campbell);
mechanism of action.4 The ease of administration gives at 90 days and had a similar safety profile. The results of Department of Neurology and
Comprehensive Stroke Center,
tenecteplase (given as a single, intravenous bolus) this trial support the use of tenecteplase in routine
Massachusetts General
unique practical advantages compared with alteplase clinical practice.6 The efficacy and safety of tenecteplase Hospital, Harvard Medical
(given as an intravenous bolus with the remainder need further assessment in other populations. School, Boston, MA, USA

www.thelancet.com Vol 401 February 25, 2023 645

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(Prof L H Schwamm MD);

Department of Neurology, Research in context
Beth Israel Deaconess Medical
Center, Harvard Medical Evidence before this study alteplase. For those receiving tenecteplase, symptomatic
School, Boston, MA, USA We searched PubMed for randomised trials published in intracerebral haemorrhage occurred in three (5%) in the
(Prof M Fisher MD); Department English between Jan 1, 2000, and July 31, 2022, with the terms 0·1 mg/kg group, none in the 0·25 mg/kg group, and two (3%)
of Neurology, LinYi People’s
Hospital, Linyi, China
“tenecteplase”, “ischaemic stroke”, and “clinical trial” or in the 0·32 mg/kg group, compared with one (2%) individual in
(Prof F Che MD); Department of “study”. Clinical effectiveness of tenecteplase has been shown the 0·9 mg/kg alteplase group. TRACE-2 was a phase 3
Neurology, Linfen Central in randomised controlled trials, and off-label routine use is randomised clinical trial informed by TRACE-1.
Hospital, Linfen, China endorsed by national practice guidelines, although the
(Prof H Dai MD); Department of Added value of this study
strength of recommendation is low. The dosages of
Neurology, Tengzhou Central There is a paucity of data on the appropriate dosage, efficacy,
People’s Hospital, Tengzhou, tenecteplase used for acute ischaemic stroke have ranged from
and safety of tenecteplase compared with alteplase in Asian
China (Prof D Li MD); 0·1 mg/kg to 0·4 mg/kg. However, the NOR-TEST 2 (part A)
Department of Neurology, populations with acute ischaemic stroke. TRACE-2 was done
trial (NCT03854500) showed worse safety and functional
Central Hospital Affiliated to across 53 hospitals in China. In this study, patients who planned
outcomes with tenecteplase at 0·4 mg/kg compared with
Shenyang Medical College, to have endovascular thrombectomy were excluded to avoid
Shenyang, China (Prof R Li MD); alteplase at the same dose. The AcT trial (NCT03889249) of
confounding of results. Therefore, TRACE-2 improves
Department of Neurology, 1600 individuals showed non-inferiority of tenecteplase at
Sinopharm Tongmei General understanding of the efficacy and safety of tenecteplase in a
0·25 mg/kg to alteplase at the same dose for excellent
Hospital, Datong, China different population.
(Prof J Wang MD)
functional outcomes at 90 days, with similar safety profiles
Correspondence to:
between the two treatments. TRACE-1 was a phase 2, Implications of all the available evidence
Prof Yongjun Wang, Department dose-finding, randomised clinical trial in China TRACE-2 found that tenecteplase was non-inferior to alteplase
of Neurology and Department of (NCT04676659). The proportion of people with acute for patients with acute ischaemic stroke ineligible for
Clinical Trial Center, ischaemic stroke who had a modified Rankin Scale score of endovascular thrombectomy. This randomised controlled trial
Beijing Tiantan Hospital,
Capital Medical University,
0–1 at 90 days when treated with tenecteplase at 0·1 mg/kg provides further evidence to support a worldwide switch to
Beijing 100070, China was 55%, at 0·25 mg/kg was 64%, and at 0·32 mg/kg was 62% tenecteplase as the preferred thrombolytic for acute ischaemic
[email protected] compared with 59% for those treated with 0·9 mg/kg stroke.
See Online for appendix

There has been a long debate about the appropriate dose Methods
of thrombolytics in Asian people with acute ischaemic Study design
stroke. The SITS-NEW study7 aimed to evaluate the The TRACE-2 trial was a phase 3, multicentre, prospective,
efficacy and safety of intravenous alteplase (0·9 mg/kg) as open-label, blinded-endpoint, randomised controlled,
thrombolytic therapy within 3 h of onset of acute non-inferiority trial across 53 centres in China. The trial
ischaemic stroke in an Asian population. This study protocol was published in 2022.11 The trial was done in
showed the safety and efficacy of the standard dose of accordance with the guidelines for Good Clinical Practice
intravenous alteplase (0·9 mg/kg) in an Asian population, and the Declaration of Helsinki and was designed and
as previously observed in the European population studied supervised by a steering committee. The trial was ethically
in SITS-MOST.8 Guidelines for intravenous thrombolysis approved by the institutional review board at the Beijing
in China,1 Europe,3 and the USA2 all recommend the dose Tiantan Hospital and at each participating site.
of 0·9 mg/kg. The ENCHANTED study,9 which assessed
low-dose (0·6 mg/kg) intravenous alteplase, did not meet Participants
the prespecified non-inferiority criteria for standard-dose Participants were eligible if they were aged at least 18 years;
intravenous alteplase. There is a paucity of data on the could receive intravenous thrombolytics within 4·5 h of
appropriate dosage, efficacy, and safety of tenecteplase as their ischaemic stroke; had a modified Rankin Scale
compared with alteplase in Asian populations with acute (mRS) score of no more than 1 before enrolment; and had
ischaemic stroke. a disabling ischaemic stroke with a National Institutes of
TRACE-1, a phase 2, dose-finding, randomised clinical Health Stroke Scale (NIHSS) score of 5–25. Eligibility for
trial in China showed that 0·25 mg/kg tenecteplase was thrombolytic treatment in this trial was based on
well tolerated in Chinese people who had acute ischaemic guidelines by the Chinese Stroke Association,1 which are
stroke, and the safety profile of tenecteplase was similar consistent with other national guidelines including US2
to that of 0·9 mg/kg alteplase.10 The aim of the and European3 guidelines. Both non-contrast CT (NCCT)
Tenecteplase Reperfusion therapy in Acute ischaemic imaging and MRI methods were acceptable for baseline
Cerebrovascular Events-2 (TRACE-2) trial was to test screening. People were ineligible for participation if they
whether tenecteplase, at a dose of 0·25 mg/kg, is non- had received or intended to proceed to endovascular
inferior to alteplase in people with an acute ischaemic thrombectomy. Additional information on inclusion and
stroke who were eligible for intravenous thrombolytic exclusion criteria is provided in the appendix (pp 2–3).
but ineligible for or refused endovascular thrombectomy Written informed consent was provided by all participants
within 4·5 h of symptom onset. or their representatives before their enrolment.

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Randomisation and masking whichever occurred first); European health-related quality

Eligible participants were randomly assigned (1:1) to of life at 90 days; and the proportion of those with a
receive intravenous tenecteplase or alteplase. Block Barthel Index score of at least 95 points at 90 days.
randomisation was done with the use of a central web- The primary safety outcome was the rate of symptomatic
based randomisation system (Randomisation and Trial intracranial haemorrhage within 36 h defined by the
Supply Management version 3.1.2, Beijing Bioknow European Cooperative Acute Stroke Study III.12 Other
Information Technology, China) with a block length of safety outcomes included parenchymal haematoma 2
four without stratification. The local investigators visited defined by the Safe Implementation of Thrombolysis in
the web-randomisation system and obtained the random Stroke-Monitoring study;8 any intra­cranial haemorrhage
codes, and the treatment assignment was done according or other significant haemorrhagic event as defined by the
to the random code. All other treatments were guided by Global Utilization of Streptokinase and Tissue
the standard of care for ischaemic stroke. Plasminogen Activator for Occluded Coronary Arteries
The intravenous thrombolytic treatment was open criteria;13 and death from all causes within 90 days of
label. Evaluators for the clinical assessments and the disease onset. Both serious adverse events and adverse
independent clinical-event adjudication committee, events were collected until 90 days. Definitions of
which adjudicated primary and secondary efficacy outcomes are included in the protocol in the
endpoints and bleeding events, were blinded to treatment appendix (p 4).
allocation.
Statistical analysis
Procedures Based on a meta-analysis of previous trials, the risk ratio
Tenecteplase was given as a single, intravenous bolus (RR) for the effect of alteplase versus placebo for the
(over 5–10 s) at a dose of 0·25 mg/kg of bodyweight excellent functional outcome (mRS score of 0–1) was
(maximum dose 25 mg) immediately after randomisation. 1·24 (95% CI 1·14–1·36).14 The non-inferiority boundary
Intravenous alteplase was given at a dose of 0·9 mg/kg was defined to preserve at least 50% of the most
(maximum dose 90 mg), with 10% of the dose given as a conservative estimate of the efficacy of alteplase from
bolus and the remainder over 1 h. Other treatments were the meta-analysis. The non-inferiority limit was
carried out adhering to established clinical principles calculated as exp(–1[(Log[1·14])/2])=0·937. Tenecteplase
and medical practice guidelines. Participants who would be declared non-inferior if the lower 97·5% one-
planned to undergo endovascular thrombectomy were sided CI of the RR for the primary outcome did not
excluded from the study. However, the recruited cross 0·937 (corresponding to 3·74% absolute risk
participants were not prohibited from subsequently difference). Assuming a power of 85%, a one-sided α
receiving endovascular thrombectomy on the basis of the level of 0·025, and an absolute RR of 1·07 based on the
judgment of the treating neurologists or physicians. phase 2 data (response rates of 63·64% for the
NCCT imaging or MRI was done to detect any tenecteplase group vs 59·32% for for the alteplase
haemorrhage at 24–36 h after randomisation. group),10 the target sample size for each group was
Clinical assessments (including clinical symptoms, 643 patients. Allowing for a dropout rate of 10%, the
laboratory tests, and imaging data) were done at each site final target sample size estimate was 1430 patients
by trained and certified evaluators who were unaware of (715 in each treatment group).
the trial group assignments at 24 h, 7 days or hospital Efficacy analyses were done in the modified intention-
discharge (whichever occurred first), and 90 days. The to-treat population and in the per-protocol population.
mRS score at 90 days was assessed in person or by The modified intention-to-treat population was defined
telephone. The clinical events committee adjudicated the as all randomly assigned participants who received the
endpoint events on the basis of clinical symptoms, allocated thrombolytic; the per-protocol population was
laboratory tests, and imaging data. Serious adverse events defined as all participants who completed the assigned
and adverse events were categorised according to standard treatment without major violation of the trial protocol or
terminology. missing data for primary efficacy endpoints. A χ² test or
Fisher’s exact probability method was used for
Outcomes comparison of categorical variables, Wilcoxon rank sum
The primary efficacy outcome was the proportion of test for comparison of ordinal variables, and t test or rank
participants with an excellent functional outcome, defined sum test for comparison of continuous variables. The
as an mRS score of 0–1 at 90 days. The secondary efficacy Cochran-Mantel-Haenszel χ² test adjusting for the
outcomes consisted of the proportion of patients with pooled-site effect (≥20 patients for each stratum) was
favourable functional outcomes (defined as an mRS score used for comparison of primary endpoints between
of 0–2 at 90 days); mRS score at 90 days; the proportion of groups, and the 95% CI of RR was calculated. We used
patients with a substantial neurological improvement on the normal approximation (Wald formula) to derive the
the NIHSS (defined as a decrease of at least 4 points, a 95% CI of absolute risk differences adjusting for the
score no more than 1 at 24 h and at 7 days, or discharge, pooled-site effect. Odds ratio (OR) with 95% CIs were

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calculated using binary logistic regression. Non- 0·937. A superiority test in the modified intention-to-treat
inferiority would be established if the lower bound of the population was planned if non-inferiority was found. For
two-sided 95% CI of the RR for the primary outcome was secondary efficacy outcomes, a common OR with its
greater than the predefined non-inferiority margin of 95% CI was calculated using ordinal logistic regression

1434 patients enrolled*

4 excluded
1 uncontrolled hypertension despite aggressive antihypertensive therapy
1 treated with heparin within 24 h
1 NIHSS score less than 4
1 sudden onset of severe headache

1430 randomly assigned

716 allocated tenecteplase 714 allocated alteplase

6 excluded with no use of study product 7 excluded with no use of study product
2 platelet counts less than 100 × 109 per L 2 history of cerebral haemorrhage
1 improvement in symptoms with NIHSS score of 3 immediately 2 withdrew consent
before thrombolysis 1 improvement in symptoms with NIHSS score of 1 immediately
1 onset-to-needle time beeyond 4·5 h after randomisation before thrombolysis
1 previous 3 month history of stroke 1 free from symptoms
1 withdrew consent 1 considered to have atrial myxoma

710 included in modified intention-to-treat analysis 707 included in modified intention-to-treat analysis

1 given alteplase 2 given tenecteplase

711 included in safety analysis 706 included in safety analysis

34 excluded 55 excluded
23 used contraindicated medications within 22 h after thrombolytic 33 used contraindicated medications within 22 h after thrombolytic
therapy therapy
4 onset-to-needle time beyond 4·5 h 5 medication compliance outside 80–120%
1 history of significant cranial trauma or stroke within 3 months 3 onset-to-needle time beyond 4·5 h
1 history of intracranial haemorrhage 2 history of intracranial haemorrhage
1 used contraindicated medication within 22 h after thrombolytic 2 history of significant cranial trauma or stroke within 3 months
therapy and had a history of gastrointestinal or urinary bleeding 2 received tenecteplase
within 3 weeks 2 had a blinded 90 day follow-up evaluation at risk of unblinding
1 used contraindicated medication within 22 h after thrombolytic 2 did not use investigational product provided by the trial
therapy and did not undergo CT before thrombolysis 1 history of significant cranial trauma or stroke within 3 months
1 received alteplase and used a contraindicated medication within 22 h after
1 medication compliance outside 80–120% range thrombolytic therapy
1 used study product beyond the storage time requirement after 1 post-seizure hemiplegia (Todd’s palsy) or combined with other
opening neurological or psychiatric disorders who was unable or unwilling
to cooperate
1 used a contraindicated medication within 22 h after
thrombolytic therapy and enrolled on oral warfarin anticoagulant
1 did not complete informed consent before randomisation

5 lost to follow-up at 3 months 11 lost to follow-up at 3 months

671 included in per-protocol analysis 642 included in per-protocol analysis

Figure 1: Enrolment and randomisation

NIHSS=National Institutes of Health Stroke Scale. *Physicians only obtained informed consent for this trial from patients who were suitable for intravenous
thrombolytic but not for endovascular thrombectomy.

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Tenecteplase Alteplase Tenecteplase Alteplase

(n=710) (n=707) (n=710) (n=707)
Age, years 67 (58–73) 65 (58–72) (Continued from previous column)
Age Baseline NIHSS score* 7 (5–10) 7 (6–10)
18–59 years 211 (30%) 218 (31%) Baseline NIHSS score categories
60–79 years 423 (60%) 428 (61%) ≤7 419 (59%) 387 (55%)
≥80 years 76 (11%) 61 (9%) 8–14 228 (32%) 261 (37%)
Sex ≥15 63 (9%) 59 (8%)
Male 492 (69%) 479 (68%) Onset-to-needle time, 180 (135–222) 178·5 (135–230)
Female 218 (31%) 228 (32%) min
Ethnicity Onset-to-needle time categories, hours
Chinese 710 (100%) 707 (100%) <3 353 (50%) 353 (50%)
Weight, kg 65 (59–75) 67 (60–75) ≥3 357 (50%) 354 (50%)
Medical history Door-to-needle time, min 58 (45–78) 61 (48–84)
Hypertension 510 (72%) 512 (72%) Bridging thrombectomy 27 (4%) 24 (3%)
Diabetes 172 (24%) 207 (29%) Total costs, yuan† 11 255·45 12 094·25
(7537·13–16849·64) (8039·37–17809·93)
Hyperlipidaemia 130 (18%) 160 (23%)
Costs for thrombolysis, 7376·00 5340·24
Coronary heart disease 167 (24%) 166 (24%)
yuan (3688·00–7376·00) (5340·24–5340·24)
Arrhythmia 137 (19%) 146 (21%)
Duration of hospital stay
Current smoking
≤7 days 125 (18%) 117 (17%)
Yes 266 (38%) 276 (39%)
>7 days 561 (79%) 574 (81%)
No 443 (62%) 430 (61%)
Data missing 24 (3%) 16 (2%)
Data missing 1 (<1%) 1 (<1%)
History of medication use Data are median (IQR) or n (%). NIHSS=National Institute of Health Stroke Scale.
*NIHSS scores range from 0 to 42, with higher scores indicating more severe
Antiplatelet agents 90 (13%) 92 (13%)
stroke. †Data available for 1360 patients (675 tenecteplase, 685 alteplase).
Anticoagulant agents 5 (1%) 7 (1%)
Lipid-lowering drugs 67 (9%) 60 (9%) Table 1: Baseline characteristics of participants in the modified
intention-to-treat population
Hypoglycaemic drugs 108 (15%) 118 (17%)
Antihypertensive drugs 296 (42%) 318 (45%)
mRS score before stroke
0 634 (89%) 633 (90%) A single primary efficacy variable was defined for this
1 76 (11%) 74 (11%) study and therefore there were no requirements to adjust
(Table 1 continues in next column) for multiple comparisons in this study and no adjustment
for multiple testing was done for secondary outcomes. No
interim analysis was planned in this trial. An independent
for the ordinal 90-day mRS score, and ORs with their data-monitoring committee reviewed the safety data
95% CIs were calculated using the Cochran-Mantel- regularly and assessed whether the study should continue.
Haenszel method adjusting for the pooled-site effect for All statistical analyses were done with use of SAS software
other secondary efficacy outcomes. The complete data (version 9.4).
were used to perform the main efficacy analyses without The trial is registered with ClinicalTrials.gov,
imputation for missing data. In sensitivity analysis, NCT04797013.
multiple imputation by fully conditional specification
logistic regression was done to impute the missing data Role of the funding source
of the primary efficacy outcome. We used the Breslow- The trial drugs, tenecteplase and alteplase, were
Day test to examine the heterogeneity of treatment effects provided free of charge to the trial sites by China
across prespecified subgroups of bridging thrombectomy. Shijiazhuang Pharmaceutical Company Recomgen
Post-hoc subgroup analyses were also done for subgroups Pharmaceutical (Guangzhou), which was the sponsor of
of sex, bridging thrombectomy, age, NIHSS, and onset- this trial but had no role in design, conduct, and report
to-needle time. of the trial. The investigators were responsible for data
Safety analyses were done in the safety analysis collection and conduct of the trial. The database was
population, defined as all participants who received at managed by the independent Giant contract research
least some of the study drug and had a safety assessment organisation. The Clinical Research Institute of Peking
available. ORs were calculated with their 95% CIs using University was responsible for the statistical analysis.
binary logistic regression. For comparison of adverse The sponsors of the study had no role in study design,
events and serious adverse events, χ² or Fisher’s exact test data collection, data analysis, data interpretation, or
were done, as appropriate. writing of the report. The responsibility for submission

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Tenecteplase Alteplase Effect size (95% CI) p value

Primary outcome (modified intention-to-treat)
mRS score 0–1 at 3 months (n=1401)* 439/705 (62%) 405/696 (58%) ·· ··
Risk ratio ·· ·· 1·07 (0·98 to 1·16)† ··
Odds ratio ·· ·· 1·19 (0·96 to 1·47) ··
Difference in proportion ·· ·· 3·86 (–1·23 to 8·95) ··
Primary outcome (per-protocol)
mRS score 0–1 at 3 months (n=1313)* 421/671 (63%) 380/642 (59%) ·· ··
Risk ratio ·· ·· 1·05 (0·97 to 1·15)† ··
Odds ratio ·· ·· 1·16 (0·93 to 1·45) ··
Difference in proportion ·· ·· 3·14 (–2·08 to 8·37) ··
Secondary outcomes (modified intention-to-treat)‡
mRS score 0–2 at 3 months (n=1401) 516/705 (73%) 502/696 (72%) 1·01 (0·95 to 1·08) 0·74
mRS at 3 months (n=1401) 1 (0 to 3) 1 (0 to 3) 1·09 (0·90 to 1·31) 0·38
Improvement on NIHSS of ≥4 points or a score ≤1 at 24 h 342/690 (50%) 345/698 (49%) 0·97 (0·88 to 1·08) 0·58
(n=1388)§
Improvement on NIHSS of ≥4 points or a score ≤1 at 7 days or 456/676 (68%) 451/686 (66%) 1·01 (0·94 to 1·09) 0·73
discharge (n=1362)
European quality of life visual analogue scale (n=1309) 77·7 (57·6 to 97·8) 76·4 (55·1 to 97·7) 1·38 (–0·87 to 3·63) 0·23
Barthel Index ≥95 (n=1320) 462/658 (70%) 454/662 (69%) 1·03 (0·96 to 1·10) 0·49

Data are n/N (%), effect size (95% CI), median (IQR), or p value. mRS=modified Rankin Scale. NIHSS=National Institutes of Health Stroke Scale. *Scores on the mRS range from
0 to 6, with 0 indicating no disability, 3 indicating moderate disability, and 6 indicating death. †Lower limit of 95% CI did not cross the non-inferiority margin of 0·937.
‡Common odds ratio with its 95% CI was calculated using ordinal logistic regression for the outcome of ordinal mRS at 90 days (proportional odds assumption test p=0·11),
β coefficient with its 95% CI was calculated using general linear model for the outcome of European quality of life visual analogue scale, and risk ratios with their 95% CIs were
calculated using the Cochran-Mantel-Haenszel method considering the site effect for other secondary outcomes. §NIHSS scores range from 0 to 42, with higher scores
indicating more severe stroke.

Table 2: Efficacy outcomes at 3 months

Modified Rankin Scale score

thrombectomy. 1434 patients were screened after written
0 1 2 3 4 5 6 informed consent and 4 were ineligible. 1430 patients
with ischaemic stroke were enrolled at 53 clinical sites in
Alteplase China (appendix pp 5–6), of whom 716 were assigned to
intention-to-treat

(n=696) 31·9 26·3 13·9 11·5 8·5 3·0 4·9

receive tenecteplase and 714 to receive alteplase (figure 1).
Modified

All enrolled participants were Chinese. Six participants

Tenecteplase
33·3 28·9 10·9 10·6 7·9 1·6 6·7
in the tenecteplase group and seven in the alteplase
(n=705)
group did not receive the study drug and were excluded
from the modified intention-to-treat analysis; the
Alteplase
32·4 26·8 13·7 11·4 7·9 2·8 5·0 modified intention-to-treat population therefore included
(n=642)
710 participants allocated to the tenecteplase group and
Per-protocol

707 to the alteplase group. The safety analysis set had 711
Tenecteplase 33·2 29·5 11·2 10·3 8·1 1·5 6·3 in the tenecteplase group and 706 in the alteplase group
(n=671)
as two patients randomised to alteplase were given
0 20 40 60 80 100 tenecteplase, and one patient randomised to tenecteplase
Proportion of patients (%) was given alteplase; patients were classified according to
the real treatment. The characteristics of the patients at
Figure 2: Distribution of modified Rankin Scale scores at 90 days in the modified intention-to-treat analysis baseline were similar between the two groups (table 1).
and per-protocol populations, according to assigned treatment
The median age of the patients was 66 years (IQR 58–73),
68·5% were men and 31·5% were women. The median
was that of the corresponding author, agreed by the trial baseline NIHSS score was 7 (IQR 6–10) across all
steering committee. participants and the median time from stroke onset to
treatment was 180 min (IQR 135–222) in the tenecteplase
Results group and 178·5 min (IQR 135–230) in the alteplase
Recruitment took place between June 12, 2021, and group. 34 tenecteplase-treated and 55 alteplase-treated
May 29, 2022. Physicians only obtained informed consent participants were excluded from the per-protocol analysis
for this trial from patients who were suitable for due to major deviation from protocol (appendix p 7). Five
intravenous thrombolytic but not for endovascular tenecteplase-treated and 11 alteplase-treated participants

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(including one participant who did not meet the inclusion –1·23 to 8·95; table 2, figure 2). The lower limit of the
criteria) were lost to follow-up at 90 days with missing 95% CI of the RR was larger than the non-inferiority
data for the primary outcomes; these participants were margin of 0·937 indicating that tenecteplase was non-
excluded from the per-protocol analysis. The concomitant inferior but not superior to alteplase. The sensitivity
medications used during hospital stay are presented in analysis with multiple imputation for missing data of the
the appendix (p 8). primary efficacy outcome showed similar results to the
In the modified intention-to-treat analysis, 439 (62%) of main analysis (appendix p 9). The proportion of patients
705 patients in the tenecteplase group and 405 (58%) of with a favourable functional outcome (mRS score 0–2) in
696 patients in the alteplase group reached the primary the tenecteplase group was 73% compared with 72% in
outcome (mRS score of 0–1 at 3 months; RR 1·07, 95% CI the alteplase group (RR 1·01, 95% CI, 0·95–1·08). No
0·98 to 1·16; proportion difference 3·86, 95% CI significant treatment effect was observed in all other

A Tenecteplase Alteplase Risk ratio pinteraction

(95% CI)

Overall 439/705 (62·3%) 405/696 (58·2%) 1·07 (0·98–1·16)

Sex 0·13
Male 312/490 (63·7%) 295/472 (62·5%) 1·01 (0·92 –1·12)
Female 127/215 (59·1%) 110/224 (49·1%) 1·20 (1·01 –1·42)
Bridging thrombectomy 0·93
Yes 10/26 (38·5%) 8/24 (33·3%) 1·35 (0·58 –3·15)
No 429/679 (63·2%) 397/672 (59·1%) 1·07 (0·98 –1·16)
Age (years) 0·28
18–59 155/209 (74·2%) 151/214 (70·6%) 1·05 (0·93 –1·19)
60–79 247/421 (58·7%) 234/423 (55·3%) 1·04 (0·93 –1·16)
≥80 37/75 (49·3%) 20/59 (33·9%) 1·47 (0·96 –2·23)
NIHSS 0·61
≤7 316/417 (75·8%) 274/383 (71·5%) 1·06 (0·97 –1·15)
8–14 110/225 (48·9%) 117/257 (45·5%) 1·06 (0·88 –1·28)
≥15 13/63 (20·6%) 14/56 (25·0%) 0·96 (0·42 –2·19)
Onset-to-needle time (hours) 0·82
<3 221/349 (63·3%) 209/349 (59·9%) 1·07 (0·95 –1·20)
≥3 218/356 (61·2%) 196/347 (56·5%) 1·06 (0·94 –1·20)

B
Overall 421/671 (62·7%) 380/642 (59·2%) 1·05 (0·97–1·15)
Sex 0·28
Male 299/465 (64·3%) 276/439 (62·9%) 1·01 (0·92–1·12)
Female 122/206 (59·2%) 104/203 (51·2%) 1·15 (0·96–1·37)
Bridging thrombectomy 0·73
Yes 10/26 (38·5%) 6/20 (30·0%) 1·49 (0·61–3·65)
No 411/645 (63·7%) 374/622 (60·1%) 1·05 (0·97–1·15)
Age (years) 0·21
18–59 146/198 (73·7%) 142/200 (71·0%) 1·04 (0·91–1·18)
60–79 238/400 (59·5%) 219/385 (56·9%) 1·02 (0·91–1·15)
≥80 37/73 (50·7%) 19/57 (33·3%) 1·50 (0·98–2·29)
NIHSS 0·67
≤7 300/397 (75·6%) 257/357 (72·0%) 1·05 (0·96–1·14)
8–14 108/215 (50·2%) 109/232 (47·0%) 1·05 (0·87–1·27)
≥15 13/59 (22·0%) 14/53 (26·4%) 0·95 (0·42–2·14)
Onset-to-needle time (hours) 0·99
<3 211/329 (64·1%) 197/325 (60·6%) 1·07 (0·95–1·20)
≥3 210/342 (61·4%) 183/317 (57·7%) 1·04 (0·91–1·17)

0·4 0·8 1·6 3·2

Favours alteplase better Favours tenecteplase

Figure 3: Effects of tenecteplase as compared with alteplase for the primary efficacy outcome in prespecified subgroups according to the modified intention-
to-treat population (A) and the per-protocol population (B)
The dashed vertical line indicates the non-inferiority limit of 0·937.

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secondary outcomes. The results of the per-protocol The AcT trial was designed as a pragmatic, registry-linked
analysis were consistent with those of the modified trial and the characteristics of its participants were similar
intention-to-treat analysis (table 2, appendix pp 9–10). to those of individuals treated in real-world practice. The
Similar efficacy was observed in the prespecified findings of the AcT trial, therefore, can be readily
subgroups (figure 3). generalised to the patient populations that the two
Symptomatic intracranial haemorrhage within 36 h registries represent. Our TRACE-2 trial was done in
occurred in 15 (2%) of 711 patients in the tenecteplase Chinese individuals. The consistent results of non-
group and 13 (2%) of 706 in the alteplase group (RR 1·18, inferiority from these two large clinical trials with
95% CI 0·56–2·50; table 3). Symptomatic parenchymal participants of very different ethnic backgrounds provide
haematoma 2 intracranial haemorrhage within 36 h robust evidence for the use of intravenous tenecteplase
occurred in ten (1%) patients in the tenecteplase group for the treatment of people with disabling acute ischaemic
and three (<1%) in the alteplase group (RR 3·73, 95% CI stroke who are not candidates for thrombectomy. In our
0·99–14·13). 46 (7%) participants in the tenecteplase TRACE-2 trial, the percentage of participants with an
group and 35 (5%) participants in the alteplase group mRS score of 0–1 was consistent with the TRACE-1 trial
died within 90 days (RR 1·31, 95% CI 0·86–2·01). Similar (NCT04676659), but higher than that from the AcT trial.
rates of adverse events and serious adverse events were Participants in TRACE-2 had lower median baseline
observed between the two groups (appendix p 11–13). No NIHSS score compared with those in the AcT trial
orolingual angioedema was found in this trial. because TRACE-2 excluded those eligible for endovascular
thrombectomy. In the AcT trial, approximately 25% of the
Discussion participants presented with large vessel occlusion on CT
In this trial, among patients with acute ischaemic stroke angiography and 505 participants underwent endo­
within 4·5 h of last known well who were eligible for vascular thrombectomy. The subgroup analysis of
intravenous thrombolysis treatment but ineligible for or participants with large vessel occlusion in the AcT trial
refused endovascular thrombectomy, we found that did not show superiority of tenecteplase. In TRACE-2,
0·25 mg/kg of intravenous tenecteplase was non-inferior however, participants eligible for or who were planned to
to 0·9 mg/kg of intravenous alteplase for achieving an undergo endovascular thrombectomy were excluded
excellent functional outcome. Although participants who from the study and only 51 (4%) individuals subsequently
received tenecteplase had numerically more mortality had endovascular thrombectomy after thrombolytic
and symptomatic intracranial haemorrhage than those treatment during the trial. A phase 2 trial (EXTEND-IA
receiving alteplase, we did not observe statistically TNK part 1 and part 2) in patients with large vessel
significant differences in the proportions of symptomatic occlusion who underwent thrombectomy after
intracranial haemorrhage nor rates of mortality between tenecteplase or alteplase suggested that tenecteplase
the two treatment groups in the 90 days after symptom might be superior to alteplase in terms of functional
onset. outcome.16,17 A meta-analysis that included four
Our findings are consistent with the results of the AcT randomised controlled trials with a total of 433 patients
trial and other published non-randomised clinical reports suggested that people with acute ischaemic stroke and
assessing off-label use of tenecteplase versus alteplase.6,15 large vessel occlusion receiving intravenous tenecteplase
might have better recanalisation and clinical outcomes
than those receiving intravenous alteplase.18 The findings
Tenecteplase Alteplase Effect size p value
of TRACE-2 trial in combination with the AcT trial further
(n=711) (n=706) (95% CI)*
strengthen the evidence for non-inferiority of tenecteplase
Symptomatic intracranial haemorrhage 15 (2%) 13 (2%) 1·18 (0·56–2·50) 0·72
compared with alteplase in treating patients with acute
within 36 h
ischaemic stroke.
Symptomatic intracranial haemorrhage 17 (2%) 15 (2%) 1·18 (0·59–2·37) 0·74
within 90 days The dose choice for thrombolytics is crucial for eligible
Parenchymal haematoma 2 intracranial 10 (1%) 3 (<1%) 3·73 (0·99–14·13) 0·053 patients with acute ischaemic stroke. The safety and
haemorrhage within 36 h efficacy of tenecteplase was previously investigated at
Any intracranial haemorrhage within 44 (6%) 50 (7%) 0·92 (0·62–1·36) 0·50 doses of 0·10 mg/kg, 0·25 mg/kg, and 0·40 mg/kg.19–25 A
90 days dose of 0·40 mg/kg did not show better efficacy than that
Other significant haemorrhage events 5 (1%) 5 (1%) 1·05 (0·29–3·90) 0·99 at 0·25 mg/kg,18 but resulted in higher rates of
within 90 days
symptomatic haemorrhage and worse clinical outcomes
Deaths 46 (7%) 35 (5%) 1·31 (0·86–2·01) 0·22
than with 0·9 mg/kg alteplase.25 In the TRACE-1 trial in
Adverse events 610 (86%) 613 (87%) 0·99 (0·95–1·03) 0·57
Chinese individuals with acute ischaemic stroke, the
Serious adverse events 116 (16%) 107 (15%) 1·10 (0·87–1·41) 0·55 safety and efficacy of tenecteplase at doses of 0·10 mg/kg,
Data are n (%), effect size (95% CI), or p value. *Risk ratios with their 95% CIs were calculated using Cochran-Mantel- 0·25 mg/kg, and 0·32 mg/kg were compared with
Haenszel method considering the centre effect. 0·9 mg/kg alteplase.10 Tenecteplase at a dose of 0·32 mg/kg
had a worse safety profile than either 0·25 mg/kg
Table 3: Safety outcomes at 3 months in the safety analysis population
tenecteplase or 0·9 mg/kg alteplase, without any trend

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towards superior efficacy. Together with the results of Acknowledgments

other previous studies, 0·25 mg/kg (maximum dose of We thank all the participants and investigators in this study and
Chen Yao and his team (Clinical Research Institute of Peking University)
25 mg) appears to be the optimal dosage for intravenous
for their key contributions as the independent statistical analysts for this
tenecteplase. Both the AcT and TRACE-2 trials used this trial. We thank National Science and Technology Major Project, Chinese
dose of tenecteplase, and 0·9 mg/kg (maximum dose of Academy of Medical Sciences Innovation Fund for Medical Sciences,
90 mg) alteplase was used as a comparison. National Natural Science Foundation of China, and China Shijiazhuang
Pharmaceutical Company Recomgen Pharmaceutical (Guangzhou) for
This study had several limitations. First, for practical
funding support.
reasons including the importance of not delaying
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