CNS-Ischemic Stroke -Use of tPA
Use of tPA for Ischemic Stroke Nearly Doubled from
2003 to 2011
Aug. 21, 2013 — Use of the "clot-busting"
drug tissue plasminogen
activator (tPA) to treat patients with strokes caused by a blockage of
blood flow nearly doubled between
2003 and 2011. In their paper receiving online release
in the journal Circulation: Cardiovascular Quality and Outcomes, a team of
researchers reports both an overall
increase in the
use of tPA to dissolve clots blocking arteries supplying
the brain and administration of the potentially life-saving drug to a more diverse group of
patients.
"Hospitals have put tremendous efforts in the
past decade into increasing the number of patients who can be treated with intravenous tPA, and this
paper suggests those
efforts are paying off," says corresponding
author Lee H. Schwamm, MD, executive vice chair of Neurology and director of
Stroke Services at Massachusetts General
Hospital (MGH) and professor of Neurology at Harvard
Medical School.. "Today, more than three-quarters of stroke patients who
are eligible for IV tPA are getting this
treatment at the more than 1,600 U.S. hospitals we
studied."
First introduced in 1996, intravenous tPA can be
administered to patients with ischemic strokes -- those caused by blockage of
blood supply -- if treatment can be started
within a few hours of the onset of symptoms. When the
drug was first introduced, the outer limit was set at 3 hours, and in 2009 it
was extended to 4.5 hours. Appropriate
use of tPA can reduce and sometimes even eliminate long-term disability
due to a stroke, but the need to administer the drug within even the extended time
window
requires rapid transportation of patients to hospital emergency
departments and quickly ruling out the possibility that the stroke is caused by
bleeding into the brain, in
which case tPA treatment would make it worse.
In 2003 the American Heart Association established Get
With the Guidelines -- Stroke (GWTG-S), a program designed to help hospitals
organize stroke teams, establish
best practices for treatment, share information with
other member hospitals and measure their performance. The current study
analyzed data on the treatment of 1.09
million acute ischemic stroke patients at 1,683 GWTG-S
hospitals during the nine-year study period.
Among all patients who were admitted to the
participating hospitals for ischemic stroke, usage of tPA increased from 4 percent in 2003 to 7 percent in 2011. In
patients
who arrived early and were without medical conditions
that would prevent safe use of the drug, tPA administration increased from 43 percent to 77
percent. Since the
researchers only analyzed data for patients arriving within 2 hours of symptom onset,
the increased tPA usage was not due to expansion of the time window.
Study results also indicated more use of tPA to treat
patients with less serious
stroke symptoms, those
aged 80 and over, and for black, Hispanic and other nonwhite
patients. "We expect that this expansion happened
because, as providers get comfortable using this drug and seeing good patient
outcomes, they become more willing to
treat all eligible patients and not just those they
feel are the 'cream of the crop' for treatment," explains Schwamm, who
also serves as the chair of the GWTG-S Clinical
Workgroup.. He adds that, while it's possible that
hospitals choosing to join GWTG-S might be more likely than others to offer the
most advanced stroke treatment, the
program has grown to the point where many U.S.
patients have access to a GWTG-S hospital.
Despite the expansion in tPA usage revealed by the
study, Schwamm stresses, the drug is still underutilized. "We should be
providing intravenous tPA to all eligible
patients, which means that nearly a quarter of them
are still missing that opportunity. Patients and their loved ones need to
recognize the signs of a stroke and get to the
hospital quickly by calling 911, and hospitals need to
be ready to provide rapid diagnosis and treatment. We hope that our results
will encourage more hospitals to join
GWTG-S or similar stroke quality improvement programs
to help accelerate their use of tPA. When patients learn that their local hospitals
are treating stroke more
aggressively, that can translate into more awareness
and faster action by the public."
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