ED docs uneasy using rt-PA to treat ischemic stroke
ED docs uneasy using rt-PA to treat ischemic stroke
Pharmacists are needed to ensure correct dose
A survey of emergency department (ED) physicians found that 40% were not likely to use recombinant tissue plasminogen activator (rt-PA) on ischemic stroke patients, even in an ideal setting. More say they might use it, however, if they had support from other health care specialists.
The study was a collaborative effort between the University of Michigan (UM) investigators in Ann Arbor and the American College of Emergency Physicians (ACEP) in Irving, TX, says Devin L. Brown, an assistant professor and stroke neurologist at U-M’s department of neurology. She also was co-author of the research, which was published in the July issue of the Annals of Emergency Medicine.
The survey, which was conducted in the summer of 2004, included responses from 1,105 ED physicians who are ACEP members. The survey wanted to determine: 1) the proportion of ED physicians resistant to using rt-PA in the ideal setting because of the risk of symptomatic intracerebral hemorrhage; 2) the proportion of emergency physicians resistant to using rt-PA in the ideal setting because of the perceived lack of benefit; 3) the highest acceptable symptomatic intracerebral hemorrhage risk; and 4) the lowest acceptable accompanying relative improvement in neurologic outcome. The FDA approved rt-PA in 1996 to treat ischemic stroke in the first three hours after the start of symptoms.
In the survey, the 40% of the ED physicians said it was very unlikely, unlikely, or uncertain that they would give rt-PA to an ideal patient in an ideal setting. Thirty-six percent said it was likely they would give the drug, and the remaining 24% said they were very likely to give it.
Of the 40% of ED physicians not likely to use rt-PA, 65% say they were concerned about the risk of symptomatic intracerebral hemorrhage, 23% report they perceived a lack of benefit of rt-PA, and 12% gave both reasons as the cause. Women physicians were twice as likely as men to be willing to use rt-PA.
The mean upper limit of symptomatic intracerebral hemorrhage tolerable was 3.4%, with associated lowest acceptable mean relative improvement of 40%. Those who were unlikely to use rt-PA had even higher standards: They wanted a maximum bleeding risk of 2.1% and a benefit of 45% relative improvement. Currently, studies show rt-PA bleeding risk to be about 6.4%, and its benefit to range from a 30% to 50% greater chance of complete or almost-complete recovery, the researchers say. Bleeding risk from clot-busting therapy for heart attack is 1%.
"Research needs to be done to see whether [a lower hemorrhage risk] can be accomplished with rt-PA in conjunction with other therapies, or whether other thrombolytics must be used to achieve this result," Brown says.
At this point, only approximately 1%-2% of stroke patients receive rt-PA, she says. "Patients often arrive too late to the emergency department to receive the drug."
Since rt-PA currently is the only FDA-approved therapy for acute ischemic stroke, Brown hopes that it will be used for all appropriate candidates until a superior alternative is identified. From discussions with ED physicians, she has learned that comfort levels increase with the use of rt-PA when ED physicians have the support of neurologists and radiologists.
Pharmacists are essential to the delivery of acute stroke therapy, as well, Brown says. "Mixing rt-PA for acute ischemic stroke needs to be viewed as an emergency. Pharmacists may also play a crucial role in identifying physician error should a physician attempt to order the cardiac dose of rt-PA for a stroke patient."
Through the use of multidisciplinary stroke teams, the use of rtPA for acute stroke patients may rise before an alternative treatment is found, she says. She recommends that people in the community also become aware of stroke symptoms and be alerted to call 911 should someone be identified with these symptoms.
When the results of this survey and other related studies were presented at a recent American Stroke Association conference, the story was picked up by the national media and presented as evidence of sloppy stroke care, writes Robert L. Wears, MD, MS, a professor in the department of emergency medicine at the University of Florida Health Science Center in Jacksonville. His comments appeared in an editorial accompanying the research. "In the press, emergency room doctors’ were singled out as unwilling to use [rt-PA] even when test results clearly show they should.’"
The abundant literature on clinicians’ failures to adopt new practices often fail to consider decisions made within the limits of a physician’s local setting, he says. "That is, that although the clinicians’ behavior might be undesirable and suboptimal from a global perspective, it might still be locally rational from their point of view."
Sloppy stroke care is a misinterpretation of the study, according to Brown. "Acute stroke care must be viewed as a team effort. Hospitals need to have an infrastructure in place to handle [these] patients."
A survey of emergency department (ED) physicians found that 40% were not likely to use recombinant tissue plasminogen activator (rt-PA) on ischemic stroke patients, even in an ideal setting. More say they might use it, however, if they had support from other health care specialists.Subscribe Now for Access
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