The FDA approved intravenous tissue plasminogen activator (tPA) for the treatment of patients with acute ischemic stroke more than 15 years ago. Dr. Mark Alberts writes in the current Journal of the American Medical Association (JAMA) that even though tPA is the only acute medical therapy proven to reduce disability and improve outcomes in these patients, it still remains vastly underutilized as a treatment. Many patients who should be treated with intravenous tPA do not receive it for reasons that are unclear, subjective or simply incorrect. Failure to treat strokes with tPA causes avoidable injury.
One study of 1200 hospitals showed that more than 1700 patients with acute stroke injury did not receive tPA therapy even though there were no exclusionary factors. It is estimated that each year thousands of patients who should receive acute tPA therapy for stroke do not. Even patients who are on coumadin are eligible for treatment with tPA if they present within a few hours of onset of symptoms.
There is no increased risk of symptomatic Intracerebral Hemorrhage (sIH) of using tPA in patients on coumadin, if their INRs are less than or equal to 1.7, and the risk of intracerebral hemorrhage with tPA therapy in these patients is 4% – 5% which is the same as non-warfarin treated patients.
The Get with The Guidelines – Stroke Registry is used extensively by approximately 900 PSCs in the United States, which are certified by The Joint Commission. PSCs are likely to have well-developed protocols for the use of intravenous tPA. Despite the evidence showing the efficacy of intravenous tPA , the real risk is in not treating otherwise eligible patients, who may then have prolonged morbidity. “A chance to treat is a chance to cure.” The results of this study show that many acute stroke patients are not getting a fair chance of cure.
If you or a loved one presents to an Emergency Room that is a Primary Stroke Center with signs of acute stroke within a few hours of onset of symptoms, treatment with tPA must be considered if the stroke is not associated with hemorrhage. In patients who meet the thrombolysis guidelines for tPA treatment, the risk of symptomatic intracranial hemorrhage is less than 5% and the chance of improved outcome is greater than 32%.