Canadian Association of Emergency Physicians Position Statement on Acute Ischemic Stroke

12 Apr

CJEM CJO masthead9Has been published in March 2015 on Canadian Journal of Emergency Medicine (CJEM), the Canadian Association of Emergency Physicians Position Statement on Acute Ischemic Stroke.

Let’s see what they say about thrombolitic therapy and administration timing.

  • THROMBOLYTIC THERAPY WITHIN 3 HOURS OF STROKE SYMPTOM ONSET

Summary of Evidence

Seven trials either specifically addressed the efficacy of rt-PA in stroke within three hours of symptom onset or provided data on a subgroup of patients receiving therapy within three hours of symptom onset.
Fibrinolytic therapy administered within three hours of symptom onset increases the probability of survival with a favourable neurologic outcome (NNT 10).
This favourable effect appears to be independent of age, including patients aged 80 and older.
Pooled data from several clinical trials suggest an important relationship between time from symptom onset to treatment and outcome. Patients treated with rt-PA within 90 minutes to symptom onset were more likely to have a favourable neurologic outcome compared to those treated from 90 – 180 minutes to treatment onset.

 

Recommendations

1. Patients with acute ischemic stroke whose neuroimaging excludes contraindications, and who can be treated within three hours of symptom onset, should be offered rt-PA with the goal of improving functional outcome (STRONG RECOMMENDATION, HIGH QUALITY EVIDENCE)
2. Stroke patients meeting eligibility criteria for thrombolytic therapy should be treated as rapidly as possible, with a target door-to-needle time of less than 60 minutes (STRONG RECOMMENDATION, MODERATE QUALITY EVIDENCE)
3. Due to limited resources and practical constraints, the administration of thrombolytic therapy within 3 hours in rural hospital may not be feasible and hence not recommended in all of these settings but should fall to the discretion of the local decision making team (WEAK RECOMMENDATION, LOW QUALITY EVIDENCE)
 
Logo MEDEST2

MEDEST COMMENT:

The statement is fair enough. The 3 hrs time window, even with the controversy that all the 7 available studies evidenced, is pretty condivisible. I love the great emphasis on ” target door-to-needle time of less than 60 minutes” that has to be the real target of all Emergency Systems. Is also well thought the flexibility on rural hospital and the assumption that treatment in those situations is discretional. Very well done i feel to subscribe everything!
 

CJEM CJO masthead9

  • THROMBOLYTIC THERAPY WITHIN 3—4.5 HOURS OF STROKE SYMPTOM ONSET

Summary of Evidence

A pooled analysis of all trials involving acute ischemic stroke patients treated in the 3.0 to 4.5 hour time window was published by Emberson et al. in 2014. Combing data from 7 studies that included 2768 patients, the likelihood of a favorable outcome was higher if patients were randomized to rt-PA. (Emberson J, Lees KR, Lyden P, et al; for the StrokeThrombolysis Trialists’ Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014;384(9958):1929-35)(.……) the latter figure (of the meta-analysis) showing significant imprecision and no difference in mortality, but a direction of effect towards a mortality increase with rt-PA in a dose-response relationship between time to treatment and 90-day mortality, suggesting a potential for increased mortality in those treated beyond 3 hours.
Included in this most recent systematic review is patient-level data from the IST-3 trial.

IST-3 suggested a 7-fold increase in symptomatic ICH associated with thrombolytic use (7% vs. 1%) as well as an expected increase in early mortality but no difference in disability or mortality at 6 months for those treated at 3–4.5 hours.

 

Recommendations

1. Thrombolytic therapy for acute ischemic stroke patients should not be routinely offered for the treatment of acute ischemic stroke for patients if administered beyond three hours of stroke symptom onset (WEAK RECOMMENDATION, MODERATE QUALITY EVIDENCE).
2. The administration of thrombolytic therapy for acute ischemic stroke beyond 3 hours from stroke symptom onset should be restricted to specialized stroke centers with advanced imaging capabilities or as part of a research protocol (WEAK RECOMMENDATION, LOW QUALITY EVIDENCE).
Logo MEDEST2

 MEDEST COMMENT:

Even for this part of the statement my agreement is total.
IST 3 that is, at the moment, the largest study on thrombolytic therapy for ischemic stroke is a total contradiction in terms of evidence about benefit and major bleeding events.
Good outcome in the first 3 hrs, a majority of adverse events between 3 and 4,5 hrs and again beneficial between 4,5 and 6 hrs. Just one consideration: the results are not suitable for clinical practice.
So Thrombolytic therapy for acute ischemic stroke patients should not be routinely offered for the treatment of acute ischemic stroke for patients if administered beyond three hours of stroke symptom onset.

This is in contrast with the 2013 AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke that states:

Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset (Class I; Level of Evidence B). The eligibility criteria for treatment in this time period are similar to those for people treated at earlier time periods within 3 hours, with the following additional exclusion criteria: patients >80 years old, those taking oral anticoagulants regardless of INR, those with a baseline NIHSS score >25, those with imaging evidence of ischemic injury involving more than one third of the MCA territory, or those with a history of both stroke and diabetes mellitus.

Bottom line:

I really like this Statement and think that is one of best available policy  about thrombolytic therapy and ischemic stroke.

References:

Logo MEDEST2

 

 
 
 

Rispondi

Inserisci i tuoi dati qui sotto o clicca su un'icona per effettuare l'accesso:

Logo WordPress.com

Stai commentando usando il tuo account WordPress.com. Chiudi sessione / Modifica )

Foto Twitter

Stai commentando usando il tuo account Twitter. Chiudi sessione / Modifica )

Foto di Facebook

Stai commentando usando il tuo account Facebook. Chiudi sessione / Modifica )

Google+ photo

Stai commentando usando il tuo account Google+. Chiudi sessione / Modifica )

Connessione a %s...

thinking critical care

a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside!

urgentcareultrasound

More definitive diagnosis, better patient care

My CPD

For WMAS clinicians

Critical Care Northampton

Reviewing Critical Care, Journals and FOAMed

OHCA research

Prehospital critical care for out-of-hospital cardiac arrest

SonoStuff

Education and entertainment for the ultrasound enthusiast

phemcast

A UK PREHOSPITAL PODCAST

First10EM

Emergency medicine resuscitation - When minutes matter...

Songs or Stories

Sharing the Science and Art of Paediatric Anaesthesia

airwayNautics

"Live as if you will die tomorrow; Learn as if you will live forever"

resusNautics

Navigating resuscitation

EMSPOCUS

Taking the hocus out of pocus and bringing hospital care to the streets.

LITFL • Life in the Fast Lane Medical Blog

Emergency medicine and critical care medical education blog

emDOCs.net - Emergency Medicine Education

Our goal is to inform the global EM community with timely and high yield content about what providers like YOU are seeing and doing everyday in your local ED.

The Collective

A Hive Mind for Prehospital and Retrieval Med

Dave on Airways

Thoughts and opinions on airways and resuscitation science

FOAMcast

A Free Open Access Medical Education Emergency Medicine Core Content Mash Up

Broome Docs

Rural Generalist Doctors Education

St.Emlyn's

Emergency Medicine #FOAMed

BoringEM

Bringing the Boring to EM

"CardioOnline"Basic and Advanced Cardiovascular medicine" Cariology" concepts and Review -Dr.Nabil Paktin,MD.FACC.دکتـور نبــــیل "پاکطــــین

این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان

EmergencyPedia

Free Open Access Medical Education

Little Medic

Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.

Prehospital Emergency Medicine Blog

All you want to know about prehospital emergency medicine

Italy Customized Travel Blog

Local Travel Agent, sommelier, food & wine expert in Florence, Italy

GoogleFOAM

The FOAM Search Engine

EM Lyceum

where everything is up for debate . . .

Pediatric EM Morsels

Pediatric Emergency Medicine Education

EM Pills

curiosità-novità-aggiornamenti in medicina d'urgenza

AmboFOAM

Free Open Access Medical Education for Paramedics

FOAM4GP

Free Open Access Meducation 4 General Practice

Rural Doctors Net

useful resources for rural clinicians

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

ECHOARTE

L'ECOGRAFIA: ENTROPIA DELL'IMMAGINE

MEDEST

Prehospital Emergency Medicine

ruralflyingdoc

Just another WordPress.com site

EM Basic

Your Boot Camp Guide to Emergency Medicine

KI Doc

WE HAVE MOVED - VISIT WWW.KIDOCS.ORG FOR NEW CONTENT

Emergency Live

Prehospital Emergency Medicine

AMP EM

Academic Medicine Pearls in Emergency Medicine from THE Ohio State University Residency Program

ERCAST Emergency Medicine Podcasts

Emergency medicine, podcasts, reviews, opinion and curbside consults

Prehospital Emergency Medicine

 Academic Life in Emergency Medicine

Prehospital Emergency Medicine

Prehospital Emergency Medicine

Greater Sydney Area HEMS

The Pre-hospital & Retrieval Medicine Team of NSW Ambulance

%d blogger hanno fatto clic su Mi Piace per questo: