Melandri et al that routine PCI after TNKase should be postponed at least 3 to 12 hours to achieve the beneﬁt. Conclusions TNKase treatment of patients with STEMI is truly evidence- based. More than 27,000 patients have been enrolled in several trials, by different investigators across the world, and address- ing all major issues: strategy of reperfusion, comparison with other thrombolytic agents, choice of the best adjunctive anti-thrombotic treatment, and optimal patient management after drug injection. For all the above considerations the American College of Chest Physicians (ACCP) recognizes TNKase as a Class 1A recommendation in the treatment of STEMI patients within 12 hours from the onset of symptoms.39 There are indeed several reasons for choosing TNKase (Table 3): the easy way it may be used in ambulance (this use is also a Class IA ACCP recommendation), the high thrombolytic potency with a decreased risk of inducing major bleeds, and the really competitive results that may be Table 3 Reasons for using TNKase in STEMI patients TNKase is the most ﬁbrin-speciﬁc thrombolytic agent available TNKase may be injected by single intravenous bolus in 5–10 seconds TNKase is as effective as accelerated rt-PA, but with less major bleeding Pre-hospital TNKase (with rescue/routine PCI) seems as effective as primary angioplasty expected for that majority of patients presenting in the ﬁrst 3 hours, compared with P-PCI. Indeed, TNKase is now embraced in many pre-hospital thrombolytic reperfusion protocols, such as the Vienna STEMI Registry,40 The Mayo Clinic STEMI Protocol,41 and The French FAST-MI registry.42 Therefore, a modern, TNKase-based “ﬁbrinolytic strategy” is now offered to the health care system, which may over- come the huge logistic problems connected with the utopian, universal P-PCI implementation. Pre-hospital TNKase is a real opportunity to offer timely reperfusion to as many patients as possible in an easy way, an opportunity that the health care system cannot miss. Table 4 summarizes how TNKase is used in clinical practice. Table 4 How to use TNKase in STEMI patients Bolus intravenous injection of TNKase over 5–10 seconds TNKase dose according to body weight (BW) 30 mg if BW 60.0 kg 35 mg if BW between 60.0 and 69.9 kg 40 mg if BW between 70.0 and 79.9 kg 45 mg if BW between 80.0 and 89.9 kg 50 mg if BW 90.0 kg Adjunctive anti-platelet therapy Aspirin: 160–325 mg, followed by 75–162 mg per day, indeﬁnitely Clopidogrel: 75 mg per day (for at least 28 days if no stenting, 1 month if using a bare metal stent, 1 year if using a drug eluting stent) Initial clopidogrel dose: 300 mg if age 75 or if a stent is implanted Adjunctive unfractionated heparin Intravenous bolus: 60 U per kg (maximum 4000 U) Intravenous infusion: 12 U per kg per hour (maximum 1000 U per hour) Target activated partial thromboplastin time: 1.5–2.0 control Treatment duration: minimum 48 hours Adjunctive enoxaparin (only if serum creatinine 2.5 mg/dL in men, 2.0 in women): Less than 75 years old: Intravenous bolus of 30 mg Less than 75 years old: Subcutaneous injection of 1 mg/kg every 12 hours At least 75 years old: No intravenous bolus At least 75 years old: Subcutaneous injection of 0.75 mg/kg every 12 hours If the creatinine clearance is 30 mL/min: subcutaneous injection every 24 hours Treatment duration: for the duration of index hospitalization, up to 8 days For patients undergoing PCI after TNKase If on unfractionated heparin: additional boluses as needed If on enoxaparin: no further anticoagulant if 8 hours from the subcutaneous injection If on enoxaparin: additional intravenous bolus of 0.3 mg/kg if 8–12 hours after the subcutaneous injection 254 Vascular Health and Risk Management 2009:5