Good call from ACEP

Summary and Comment
t-PA for Acute Stroke: Will It Ever Be Accepted as Standard of Care?
The FDA approved the use of t-PA for acute stroke almost a decade ago, yet despite strong evidence that such treatment is effective, emergency physicians have not embraced it as standard of care or even as a therapeutic option. To assess attitudes about t-PA use for acute ischemic stroke, researchers surveyed a random sample of 2600 American College of Emergency Physicians (ACEP) members, who were solicited by e-mail. Of 1105 physicians who responded to the web-based or paper survey (43% response rate), 45% reported that they were not likely to use t-PA, even under ideal conditions. Of these respondents, 65% cited risk for intracerebral hemorrhage (ICH) as the reason they would not use t-PA, 23% cited lack of perceived benefit, and 12% cited both reasons. Overall, about 30% of respondents reported that their decision whether to use t-PA was based on personal experience. Among all respondents, the mean upper limit of ICH risk considered to be acceptable was 3.4%, and the mean lowest relative improvement in neurologic outcome considered acceptable was 40% (in the subset of respondents unwilling to use t-PA, corresponding percentages were 2.1% and 45%). Demographic factors associated with willingness to use t-PA were female sex (odds ratio, 2.30) and previous use of t-PA for acute stroke (OR, 3.13). Comment Since the original National Institute of Neurological Disorders and Stroke (NINDS) study, many other large prospective trials have consistently shown therapeutic benefit of t-PA for acute stroke (JWEM Jun 28 2005). These studies also have demonstrated that excessive rates of ICH most often result from protocol violations (giving t-PA to patients who shouldn’t get it). Despite the large body of evidence supporting t-PA, the American Academy of Emergency Medicine and the Society for Academic Emergency Medicine do not support t-PA as standard of care treatment for acute stroke, and ACEP has stated that t-PA might be beneficial if there is adequate institutional support.
It is peculiar that physicians would set personal limits of risk and benefit other than those supported by the evidence, and it is troubling that personal experience, rather than evidence, would be used as the basis for deciding whether to give t-PA. Efforts should now focus on obtaining necessary resources to provide this proven therapy. Perhaps it is time for the professional societies to analyze more-recent evidence and update their recommendations. — Richard D. Zane, MD, FAAEM Published in Journal Watch Emergency Medicine September 27, 2005