As you all may be aware, there is a fair amount of controversy surrounding the use of tPA in acute ischemic stroke. This becomes even more apparent when you talk about extending the “stroke window” to 4.5 hours. Rather than give you my personal opinion on this topic, I want to give you all a list of resources so that you can be well-informed and make your own decision. To do this properly will take some time on your part, but I promise you that this issue is not going away anytime soon. You need to fully understand this medicine so that if you give it to a patient and they die of an intracranial hemorrhage, you still feel that you did what was best for that patient at that time. Below are some recommended things to check out, including stuff that has been released in the past month.
1. Podcasts. There are several extremely high quality podcasts on the topic. If you want the quicker one (55 minutes), check out “Acute Ischemic Stroke” from the Oct 14, 2013 podcast of ERCast. Very good, but an overview. If you really really want all of the details and want to fully understand this topic, check out the June 28, 2012 episode of SMARTEM entitled “Thrombolytics for Acute Stroke” (2h, 35 min) and the August 12, 2013 update entitled “Thrombolytics for Stroke: Update” (1h, 23 min). I have listened to both of these twice because the information is so important, and they make the discussions fun.
2. You can always read the original articles and interpret the findings for yourself. The show notes for the above podcasts list the articles. Here is a link to the classic NEJM articles (about the NINDS studies): NEJM article
Of all of the tPA studies to know, NINDS may be the most important because it was the basis for the recommendations to give tPA to our patients. You should know about this study, and it is very helpful to look at the “Letters to the Editor” (you can click directly to these from the article) and see why a number of smart people didn’t like the study. They actually had to do 2 NINDS studies because NINDS-1 (looking at 24 hour outcomes) did not show any benefit to tPA. For those of you thinking, “I gave a patient tPA and they were much better 2 hours later”, it’s probably because you tPA’ed a TIA. Very interesting stuff.
3. Check out the March, 2015 edition of ACEP Now (it’s that monthly newsletter that we all get and occasionally read). Here is the link. Essentially, the clinical guidelines recommending tPA are changing. They used to be level A recommendations and there was such outrage that they are changing to level B. Below is a screenshot from the cover of the newsletter.
4. This is not a recommendation of something to read, but I wanted to share with you an item I received in the mail within the past month. It is pictured below and appears to be an update on stroke management. Look at the company that sponsored it (I zoomed in on it in the second picture). Guess what drug Genentech manufactures? Thought this was interesting as Genentech has their hands in a lot of the “research” that is being done on tPA and I felt this was particularly egregious to send something that looks like it might be legit (and you get CME for reading the article!) that is full of biased tables and charts (I can show it to anyone that’s interested).
Ok, that’s it for now. Just wanted you all to be aware of this current debate and to form an opinion on the matter. Ask your attendings how they feel about it. You’ll get wildly different answers from different attendings (trust me, I’ve already asked), and people tend to feel pretty strongly one way or another because the topic is so polarizing. Please post your thoughts and comments below!! And no, I’m not completely anti-tPA, I just personally don’t feel that we have narrowed down which patients will benefit and which won’t, and to give it to everyone indiscriminately seems not right to me…