Utilization and outcome of thrombolytic therapy for acute stroke in Pakistan

Abstract

Our objective was to identify the outcome of patients treated with tissue plasminogen activator (r-tPa) in Pakistan and compare these data to available regional and international data. The charts of all patients treated with r-tPa for acute stroke at two centers in Pakistan (Aga Khan University, Karachi and Liaquat National hospital, Karachi) were retrospectively reviewed. We identified 21 patients. The utilization of tPa at Aga Khan Hospital was 18/1,185 patients (1.5%) from 2005 to 2007 while at Liaquat National Hospital was 3/575 patients (0.52%) over 1 year (2007). Mean time interval between stroke onset and start of r-tPa infusion was 169 min. Three patients (14%) developed fatal hemorrhage and two (10%) developed non-fatal hemorrhage. Four patients (19%) died. We identified protocol violations in seven patients (33%). In conclusion, the utilization of thrombolytic therapy is low and complication rate is high. Interventions for training physicians are needed.

Gaps and Hurdles Deter against Following Stroke Guidelines for Thrombolytic Therapy in Iran: Exploring the Problem

“…A recent systematic review 17 assessed the global use of rtPA for AIS among 214 countries and found that only 54 (25%) of these countries reported its administration, ranging from as low as 3% (1 of 36) of low-income, to 13% (7 of 54) of lower middle-income, to 28% (15 of 54) of upper middle-income, and to 44% (31 of 70) of highincome countries. 17 In comparison, access to rtPA in Iran is lower than in most of the developed countries [18][19][20][21][22][23][24][25] but comparable with other developing countries [26][27][28][29][30][31][32] ( Fig 2). The barriers of timely administration of rtPA in developing countries include limited resources, prehospital delay, sparse numbers of stroke units, 16,33 poor stroke awareness in the general population, 33 lack of general knowledge and professional education, 33,34 the high cost of rtPA, lack of insurance coverage, low socioeconomic status of patients, 16,33 and physician reluctance and concerns about the benefits compared with its serious side effects, especially bleeding.…”

Strategies to Improve Stroke Care Services in Low- and Middle-Income Countries: A Systematic Review

“…Following its success, “Brazilian National Stroke Policy Act” was implemented, which reduced the cost of rTPA from USD 2,000/patient to USD 540/patient [27]. In Egypt, <1% of eligible patients were thrombolysed [45,] while no more than 2% of patients are thrombolysed in Pakistan and Iran [34,50]. This figure is somewhat better in the “Indo-US Collaborative Stroke Project,” where 227 of 2066 (11%) patients in 5 centres across the country received thrombolysis.…”

Eligibility Assessment for Intravenous Thrombolytic Therapy in Acute Ischemic Stroke Patients; Evaluating Barriers for Implementation

“…Over 80% of all stroke deaths, worldwide, occur in the developing countries (7). Adults in low- and middle-income countries are at a 30% greater risk of death from non-communicable diseases than their counterparts in high-income countries (8), nonetheless, in developing countries thrombolytic therapy for patients with AIS is available for only 1–3% of patients and mostly in urban areas (9-13), while in developed countries, this ratio is as high as 10% (14) or even higher (15). Iran is a developing country with stroke prevalence of 23–103 per 100,000 population (7, 13).…”