by Our bodies are wonderfully designed with many complex mechanisms working in harmony to maintain homeostasis. One such important mechanism is our coagulation system which helps control bleeding when we suffer an injury. However, in some conditions like heart attacks or strokes, abnormal clots can form blocking arteries and depriving tissues of oxygen-rich blood. Thankfully, our bodies also produce compounds that can dissolve such clots when needed. One such powerful clot dissolving agent is Tissue Plasminogen Activator or TPA.
Discovery and Biochemistry
TPA was discovered in the early 1980s independently by scientists trying to understand the process of fibrinolysis or clot dissolution in our body. It was found that TPA catalyzes the conversion of plasminogen, an inactive form of the protease plasmin, to its active form plasmin. Plasmin then acts to break down the cross-linked fibrin fibers that form the structural basis of a blood clot. TPA is a serine protease produced primarily in the endothelial cells lining our blood vessels. It helps initiate the clot lysis or dissolution process by activating plasminogen only on fibrin surfaces within a blood clot.
Role in Stroke Treatment
With the discovery of its clot busting properties, researchers soon realized TPA’s potential in treating ischemic strokes caused by clots blocking arteries supplying blood to the brain. However, early clinical trials in the 1990s showed treating stroke patients with TPA increased the risk of hemorrhagic transformations and intracerebral hemorrhages if given beyond 4.5 hours of symptom onset. Due to this, in 1996 the FDA first approved intravenous recombinant TPA (rtPA) treatment for acute ischemic stroke within 3 hours of symptom onset. Subsequent trials expanded this therapeutic window to 4.5 hours. Even though risks remain, proper patient selection and timely treatment within the window period can significantly improve patient outcomes by restoring blood flow.
Administration and Monitoring
For stroke treatment, Tissue Plasminogen Activator is administered as an intravenous infusion over 60 minutes with 10% of the total dose given as an initial bolus over 1 minute. The standard dose is 0.9 mg/kg body weight. This only distributes a very small amount (2-3 mg) of the drug systemically. Monitoring for bleeding complications is crucial after treatment with CT scans and neurologic exams. Patients are also carefully screened beforehand to rule out conditions that increase bleeding risk like recent brain hemorrhages. Due to its short half-life, effects of TPA are relatively transient with clot lysis peaking at around 90 minutes. This narrow therapeutic window necessitates rapid assessment and treatment.
Myocardial Infarction
While intravenous TPA is the standard treatment for ischemic strokes, its role in myocardial infarction or heart attack management has been more restricted. This is because clots forming during heart attacks are usually in the coronary arteries supplying the heart muscle itself making the risks of bleeding higher. However, some clinical guidelines do allow for fibrinolytic drugs like TPA to be considered as part of early management in select STEMI or ST-elevation myocardial infarction cases not immediately amenable to angioplasty when given within 12 hours of symptom onset and with transfer to sites capable of cardiac catheterization and stenting.
Adjunctive Therapies
Alone, intravenous TPA has shown only modest benefits in stroke due to many factors limiting its efficacy like clot composition, location and size. Therefore, combination therapies aimed at improving revascularization rates are being explored. These include using ultrasound or mechanical thrombectomy devices to physically break up clots along with TPA. Studies have also looked at pretreating with drugs like antiplatelets that make clots more susceptible to lysis. Ongoing research continues to evaluate newer TPA dosage regimens and adjunctive strategies that may widen the therapeutic window while maintaining safety in ischemic stroke patients.
Tissue Plasminogen Activator is a profoundly important endogenous substance produced by our bodies that helps regulate fibrin clot formation and lysis. Its unique properties as a highly specific clot activator contributed greatly to establishing modern stroke treatment protocols. While risks exist, TPA remains a valuable first-line therapy and its role continues expanding with improvements in patient selection, co-therapies and reduced time windows to reperfusion. Future research holds promise to further optimize TPA’s impact on the number of lives and disabilities saved from thromboembolic vascular events.
*Note:
1. Source: Coherent Market Insights, Public sources, Desk research
2. We have leveraged AI tools to mine information and compile it
