Why are acute ischemic stroke patients not receiving IV tPA?

Messé, Steven R.; Khatri, Pooja; Reeves, Mathew J.; Smith, Eric E.; Saver, Jeffrey L.; Bhatt, Deepak L.; Grau‐Sepulveda, Maria V.; Cox, Margueritte; Peterson, Eric D.; Fonarow, Gregg C.; Schwamm, Lee H

doi:10.1212/wnl.0000000000003198

Cited by 170 publications

(134 citation statements)

References 44 publications

(43 reference statements)

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“…However, the addition of local or “site-specific” (non-standard) eligibility criteria may result in otherwise eligible patients not receiving rtPA. There is a growing evidence base on the additional reasons for low rtPA treatment rates, including the fit between eligibility criteria and actual patient selection practices [17-19]. In particular, many of the criteria used in clinical trials may no longer be relevant given that the drug was first approved over 20 years ago [20-22].…”

Section: Introductionmentioning

confidence: 99%

Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA

et al. 2018

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Background: Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke; however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. Methods: Surveys were mailed to 566 eligible hospitals in Australia (AUS), the UK, and the USA. Criteria were pre-classified as standard (approved indication and contraindications) or non-standard (approved warning or researcher “decoy”). Percentage for criterion selection was calculated/compared; linear regression was used to assess the association between use of non-standard criteria and rtPA treatment rates, and to identify factors associated with addition of non-standard criteria. Results: Response rates were 74% AUS, 65% UK, and 68% USA; mean rtPA treatment rates were 8.7% AUS, 12.7% UK, and 8.7% USA. Median percentage of non-standard inclusions was 33% (all 3 countries) and included National Institutes of Health Stroke Scale (NIHSS) scores > 4, computed tomography (CT) angiography documented occlusion, and favourable CT perfusion. Median percentage of non-standard exclusions was 25% AUS, 28% UK, and 60% USA, and included depressed consciousness, NIHSS > 25, and use of antihypertensive infusions. No AUS or UK sites selected 100% of standard exclusions. Conclusions: Non-standard criteria for rtPA eligibility were evident in all three countries and could, in part, explain comparably low use of rtPA. Differences in the use of standard criteria may signify practitioner intolerance for those derived from original efficacy studies that are no longer relevant.

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Section: Introductionmentioning

confidence: 99%

Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA

et al. 2018

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“…Amongst the main reasons for treatment retention of IVRTPA eligible AIS patients in stroke care nowadays are minor and/or regressing symptoms (‘too good to treat’) . This also applies to the majority (84%) of cases in our cohort of IVRTPA eligible AIS patients without specific reperfusion treatment.…”

Section: Discussionmentioning

confidence: 77%

Endovascular stroke treatment does not preclude high thrombolysis rates

Feda¹,

Nikoubashman²,

Schürmann³

et al. 2018

Euro J of Neurology

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Background and purpose In 1995 intravenous recombinant tissue plasminogen activator (IVRTPA) was the first reperfusion therapy to be approved in patients with acute ischaemic stroke (AIS). The significance and impact of IVRTPA in times of modern endovascular stroke treatment (EST) were analysed in a German academic stroke centre. Methods A retrospective observational cohort analysis of 1034 patients with suspected AIS presenting at the emergency department in 2014 was performed. Patients were evaluated for baseline characteristics, reperfusion procedures, IVRTPA eligibility, clinical outcome, symptomatic intracranial haemorrhage (sICH) and mortality. Data acquisition was part of an investigator‐initiated, prospective and blinded end‐point registry. Results In 718 (69%) patients the diagnosis of symptomatic AIS was confirmed. 419 (58%) patients presented within 4.5 h of symptom onset and of those 260 (62%) received reperfusion therapy (IVRTPA alone, n = 183; combination or bridging therapy, n = 60; EST alone, n = 17). Subtracting cases with absolute contraindications for IVRTPA resulted in an effective thrombolysis rate of 82%. sICH occurred in two patients treated with IVRTPA alone (1.1%). The median door‐to‐needle interval was 30 min. Fifty (17%) non‐EST eligible AIS patients presenting within 4.5 h without absolute contraindications did not receive IVRTPA mainly due to mild or regressive symptoms. Most of these untreated IVRTPA eligible patients (82%) were discharged with a good clinical outcome (modified Rankin Scale ≤ 2). Conclusions Intravenous recombinant tissue plasminogen activator remains the most frequently applied reperfusion therapy in AIS patients presenting within 4.5 h of onset in a tertiary stroke centre. An effective thrombolysis rate of over 80% can be achieved without increased rates of sICH.

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“…1 Unfortunately, there is significant variability in the treatment of people with mild stroke based on where they are admitted, with better care being associated with certified stroke centers. 50 A clear definition of mild stroke is needed to ensure best care despite admission location and to reduce health care disparities.…”

Section: Discussionmentioning

confidence: 99%

Classification of Mild Stroke: A Mapping Review

Schwartz

Capó-Lugo

Akinwuntan

et al. 2019

PM&R

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Persons with mild stroke experience motor and cognitive impairments that negatively affect their health and quality of life. To address these deficits, it is essential for clinicians and researchers to precisely identify mild stroke survivors. Despite the fact that half of all strokes are categorized as mild, no standards exist on what constitutes a “mild” stroke. The purpose of this study is to summarize the current classification of mild stroke using a mapping review approach. Strategies to categorize “mild stroke” severity were explored in 188 papers indexed in the PubMed database. The results indicate that there was substantial variability in the procedures and scoring criteria used to determine mild stroke. To identify persons with mild stroke, researchers have largely applied assessment instruments developed to inform acute stroke care (eg, National Institutes of Health Stroke Scale, Modified Rankin Scale, Barthel Index). Unfortunately, these approaches demonstrate floor effects and fail to detect the long‐term disabling impairments that often limit the outcomes of mild stroke survivors. Additional research is warranted to suggest an evidence‐based mild stroke categorization strategy that enhances diagnosis, treatment, and referral decisions to the benefit of mild stroke survivors.

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Why are acute ischemic stroke patients not receiving IV tPA?

Cited by 170 publications

References 44 publications

Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA

Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA

Endovascular stroke treatment does not preclude high thrombolysis rates

Classification of Mild Stroke: A Mapping Review

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