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Wednesday, June 19, 2013
Ahead of Print: tPA for Stroke
‘tPA is What We Have’
Editor:
The American College of Emergency Physicians (ACEP) and American Academy of Neurology’s (AAN) joint policy on using intravenous tPA for managing acute ischemic stroke in the emergency department was developed after an exhaustive review of the medical literature and involved extensive evaluation by emergency physicians, the Society for Academic Emergency Medicine, the Emergency Nurses Association, the American College of Physicians, the Neurocritical Care Society, and the American Stroke Association. The sole funding sources for the development and publication of this clinical policy were ACEP and AAN. (“The ‘Biggest, Baddest’ Controvery in EM,” EMN 2013;35[4]:1; http://bit.ly/12F9m4r.)
 
The expansion of the treatment time window to 4.5 hours is in accord with the European Cooperative Acute Stroke Study. The American Academy of Emergency Medicine’s 2012 position statement on tPA, contrary to what is stated in your article, supports the ACEP and AAN clinical policy, and offers no caveat about tPA not being a standard of care.
 
Nothing we do in emergency medicine comes without risk, and many things we don’t do carry substantial risk as well. The world of emergency medicine is still divided over using tPA to treat acute ischemic stroke, but the stroke patient community is not: 88 percent of lawsuits involving tPA ischemic stroke therapy were filed over failure to treat with tPA. (Ann Emerg Med 2008;52[2]:160.) Less than two-thirds of plaintiffs prevailed, but of those who did, 83 percent involved failure to treat.
 
In the absence of something better, we work with what we have to reduce death and disability from stroke, and tPA is what we have. Nobody is more invested in improving treatment options for this devastating injury than emergency physicians and neurologists. ACEP worked with the AAN on revising the clinical policy at the urging of our members. It reflects more than 10 years of work by emergency physicians who are extraordinarily sensitive to the potential serious effects of any physician treatment choices as well as the valid concerns of physicians who might administer it.
 
The policy is not compulsory; it is merely a recommendation and leaves the final treatment decision to the physician. It also spells out that the hospital must have a system in place for treating stroke patients or the ability to transfer these patients to facilities that can before administering tPA.
 
Andy Sama, MD
President, ACEP

Editor’s Note: Dr. Sama’s letter notes that the American Academy of Emergency Medicine’s position statement on tPA supports the ACEP and AAN clinical policy and offers no caveat about tPA not being a standard of care. The following statement, however, verbatim from AAEM’s website, notes: “It is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care. Until additional evidence clarifies such controversies, physicians are advised to use their discretion when considering its use. Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke.” (Read AAEM's policy statement at http://bit.ly/Wlwm9N.)
 
Robert McNamara, MD, a past president of AAEM and a professor and the chair of emergency medicine at the Temple University School of Medicine, said the confusion may have resulted from an email issued by the Centers for Disease Control and Prevention stating that the academy endorsed tPA for stroke. The CDC was referring to a Clinical Practice Advisory issued by AAEM and not a position statement. AAEM set the record straight in a letter to the CDC requesting a correction. (Read the letter at http://bit.ly/150ejbX.)
 
AAEM stated that tPA is one treatment option for stroke when given in academic medical centers and prepared stroke centers, and called for EPs to have the resources, such as a stroke team, to optimally care for suspected stroke patients. The letter also said hospitals should formulate a plan for timely care of patient with suspected acute stroke. The full AAEM Clinical Practice Advisory is available at http://bit.ly/AAEMtPApolicy.
About the Author

Lisa Hoffman
Editor, Emergency Medicine News

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