Twenty-Year History of the Evolution of Stroke Thrombolysis With Intravenous Alteplase to Reduce Long-Term Disability

Campbell, Bruce C.V.; Meretoja, Atte; Donnan, Geoffrey A.; Davis, Stephen M.

doi:10.1161/strokeaha.114.007564

Cited by 62 publications

(38 citation statements)

References 48 publications

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“…The eligibility criteria for rtPA administration varies between countries [32-35]. The European and Australian guidelines share many similarities, but these differ substantially from the USA guidelines, and the USA guidelines vary significantly from the drug’s approved indications and contraindications.…”

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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“…Despite the American Food and Drug administration approval of the IV t-PA for stroke within 3 hours of symptoms onset in 1996, dissenting opinion and an attitude of antagonism toward t-PA among some medical groups continued. The concern raised was about the high risk of intracranial bleeding, potential effect of imbalance in baseline stroke severity between the two treatment groups in NINDS trial favoring the t-PA group, and the generalizability of the study [10]. However, the concern of imbalance in baseline stroke severity was refuted in a subsequent comprehensive and independent reanalysis of data [11].…”

Section: Discussionmentioning

confidence: 99%

Knowledge and Attitudes of Saudi Emergency Physicians toward t-PA Use in Stroke

Khathaami

Aloraini

Almudlej

et al. 2018

Neurology Research International

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Background and Objectives Tissue plasminogen activator (t-PA) within 4.5 hours from onset improves outcome in patients with ischemic stroke and has been recommended by several international guidelines. Since its approval in 1996, the debate among emergency physicians continues particularly around the result interpretation of the first positive randomized controlled trial, the National Institute of Neurological Disorders and Stroke (NINDS) clinical trial. This lack of consensus might negatively affect the delivery of effective stroke care. Here we aimed to assess the knowledge and attitude of Saudi emergency physicians toward t-PA use within 4.5 hours of onset in acute ischemic stroke. Methods A web-based, self-administered, locally designed questionnaire was sent to all emergency physicians practicing in the city of Riyadh from January to September 2017. Results Out of 450 emergency physicians, 122 from ten hospitals in Riyadh participated in the survey, with a 27% response rate. The majority of participants were men (78%), and their mean age was 40 ± 8 years. Half of the participants were board certified, and 36% were consultants. Half of the participants consider the evidence for t-PA use in stroke within 4.5 hours of stroke onset to be controversial, and 41% recommend against its use due to lack of proven efficacy (37%), the risk of hemorrhagic complications (35%), lack of stroke expertise (21%), and medicolegal liability (9%). Nearly half were willing to administer IV t-PA for ischemic stroke in collaboration with remote stroke neurology consultation if telestroke is implemented. Conclusion Our study detected inadequate knowledge and a negative attitude among Saudi emergency physicians toward t-PA use in acute stroke. This might negatively impact patient outcome. Therefore, we recommend developing urgent strategies to improve emergency physicians' knowledge, attitudes, and beliefs in the management of acute stroke.

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“…For all stroke patients eligible for IV tPA, the NNT to achieve an excellent outcome (modified Rankin Scale (mRS) score 0 or 1) is 1 in 8 if administered within 3 h and 1 in 14 if administered within 3–4.5 h 27. However, given the low rate of recanalization overall in patients with ELVO, the NNT to achieve an excellent outcome for IV tPA in patients with ELVO will be significantly higher overall, particularly in the 3–4.5 h range.…”

Section: Tpa: Role In Patients Eligible For Embolectomymentioning

confidence: 99%

Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value?

Chandra

Leslie‐Mazwi

Derdeyn

et al. 2016

J NeuroIntervent Surg

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As healthcare delivery in the USA transforms into a model that at its core requires value-based considerations, ischemic stroke is confronted by intersecting forces. Modern techniques allow rapid revascularization in the majority of patients with large vessel occlusions. Dramatic advances in the evidentiary basis for mechanical embolectomy are increasing the number of patients treated with this therapy. A key part of the therapeutic arsenal in many patients treated with interventional techniques has been concurrent intravenous thrombolysis. We consider whether this paradigm warrants change.

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Twenty-Year History of the Evolution of Stroke Thrombolysis With Intravenous Alteplase to Reduce Long-Term Disability

Abstract: (A.M.). The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl

Cited by 62 publications

References 48 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

Knowledge and Attitudes of Saudi Emergency Physicians toward t-PA Use in Stroke

Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value?

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