Background and Purpose-Guidelines for intravenous tissue plasminogen activator (tPA) use in stroke emphasize the importance of limiting its use to facilities with imaging capabilities and stroke expertise. This prospective case series set out to evaluate the safety of tPA use in patients referred from rural communities to a tertiary center. Methods-Prospective data of 82 consecutive patients treated with tPA in London, Ontario, were reviewed. Results-Twenty-three patients were transferred to London from a rural hospital (non-London patients); 49 were first evaluated in a London emergency room (London ER); and 10 were inpatients in a London hospital at the time of stroke onset. Mean transfer time and distance to London for non-London patients were 89 minutes and 41 miles. Although symptom onset to London ER times were longer for non-London than for London ER patients (123 versus 53 minutes), the door to needle times were significantly shorter for the former (49 versus 95 minutes, PϽ0.005). Imaging to needle times were longer for London inpatients compared with London ER patients (55 versus 36 minutes, Pϭ0.16). The proportion of patients with Ͼ4-point improvement on the NIH Stroke Scale or cure at 24 hours was 57%, with no difference among groups (Pϭ0.46). The overall symptomatic hemorrhage rate at 36 hours was 2%. No significant differences in outcomes were observed at 3 months. Conclusions-This prospective study suggests that it is feasible and safe to treat rural patients referred to a tertiary care center with tPA, thus extending the benefits of thrombolysis for acute stroke to a wider population. Key Words: Canada Ⅲ stroke, acute Ⅲ stroke management Ⅲ thrombolytic therapy Ⅲ tissue plasminogen activator T he National Institute of Neurological Disorders and Stroke (NINDS) tPA Stroke Study Group showed in 1995 that intravenous tissue plasminogen activator (tPA) was an efficacious treatment for acute ischemic stroke. 1 Since its approval by the FDA in 1996, tPA has been used safely and effectively in routine clinical practice in urban academic medical centers 2-7 and in community hospitals. 2,8 Strategies to extend thrombolysis to rural community hospitals with imaging and intensive care facilities but with limited stroke expertise 5,9 and referral protocols for urban community hospitals that have limited access to imaging facilities 10 have been implemented successfully.Guidelines have been developed to ensure safety in the use of tPA for acute ischemic stroke. [11][12][13] Routine tPA use is currently restricted to those patients who can be treated within 3 hours of symptom onset. All the guidelines emphasize the importance of involving physicians with expertise in the diagnosis of stroke and in the interpretation of CT scans and restrict treatment to facilities that have the ability to handle hemorrhagic complications. Many hospitals, particularly outside the United States, 10,14 lack the staff or the facilities required to meet these criteria.In February 1999, the Health Protection Branch of Canada granted a ...
The last ten years have seen rapid strides in the evolution of nonvitamin K oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). For the preparation of this consensus, a comprehensive literature search was performed and data on available trials, subpopulation analyses, and case reports were analyzed. This Indian consensus document intends to provide guidance on selecting the right NOAC for the right patients by formulating expert opinions based on the available trials and Asian/Indian subpopulation analyses of these trials. A section has been dedicated to the current evidence of NOACs in the Asian population. Practical suggestions have been formulated in the following clinical situations: (i) Dose recommendations of the NOACs in different clinical scenarios; (ii) NOACs in patients with rheumatic heart disease (RHD); (iii) Monitoring anticoagulant effect of the NOACs; (iv) Overdose of NOACs; (v) Antidotes to NOACs; (vi) Treatment of hypertrophic cardiomyopathy (HCM) with AF using NOACs; (vii) NOACs dose in elderly, (viii) Switching between NOACs and vitamin K antagonists (VKA); (ix) Cardioversion or ablation in NOAC-treated patients; (x) Planned/emergency surgical interventions in patients currently on NOACs; (xi) Management of bleeding complications of NOACs; (xii) Management of acute coronary syndrome (ACS) in AF with NOACs; (xiii) Management of acute ischemic stroke while on NOACs.
Atrial fibrillation (AF), the most prevalent cardiac arrhythmia encountered in clinical practice, is linked with substantial morbidity and mortality due to accompanying risk of stroke and thromboembolism. Patients with AF are at a five-fold higher risk of suffering from a stroke. Anticoagulation therapy, with either vitamin K antagonists or novel oral anticoagulants (NOACs), is a standard approach to reduce the risk. Consultant physicians (CPs) in India are the primary point of contact for the majority of patients before they approach a specialist. The CPs may face challenges in screening and diagnosing AF patients. The apprehensions associated with managing AF patients with anticoagulants, further add to the challenges of a CP. This review aimed to identify the key decision points for the CPs to diagnose AF and initiate anticoagulation in patients with non-valvular AF (NVAF) and bring to the table a simplified recommendation supported by expert opinion and guidelines for stroke prevention in NVAF patients.
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