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Study finds sizable increase in use of tPA to treat stroke

Thursday August 22, 2013
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Use of tissue plasminogen activator to treat patients with ischemic stroke nearly doubled between 2003 and 2011 and was administered to a more diverse group of patients, according to a study.

"Hospitals have put tremendous efforts in the past decade into increasing the number of patients who can be treated with intravenous tPA, and this paper suggests those efforts are paying off," Lee H. Schwamm, MD, the study’s corresponding author and executive vice chair of neurology and director of stroke services at Massachusetts General Hospital, said in a news release.

Among stroke patients eligible for IV tPA at the 1,600 hospitals studied, more than three-quarters are getting the treatment, said Schwamm, also professor of neurology at Harvard Medical School.

First introduced in 1996, intravenous tPA can be administered to patients with ischemic stroke if treatment is started within a few hours of the onset of symptoms. The outer limit, initially set at three hours, was extended to 4.5 hours in 2009, according to the news release. Appropriate use of tPA can reduce and sometimes even eliminate long-term disability due to a stroke, but the need to administer the drug within the time window requires rapid transportation of patients to EDs and quickly ruling out the possibility of hemorrhagic stroke.

In 2003 the American Heart Association established Get With the Guidelines-Stroke, a program designed to help hospitals organize stroke teams, establish best practices for treatment, share information with other member hospitals and measure their performance. For a study published Aug. 20 on the website of the journal Circulation: Cardiovascular Quality and Outcomes, Schwamm and colleagues analyzed data on the treatment of 1.09 million acute ischemic stroke patients at 1,683 GWTG-S hospitals during the nine-year study period.

Among all patients who were admitted to the participating hospitals for ischemic stroke, usage of tPA increased from 4% in 2003 to 7% in 2011. In patients who arrived early and did not have medical conditions that would prevent safe use of the drug, tPA administration increased from 43% to 77%. Since the researchers analyzed data only for patients arriving within two hours of symptom onset, the increased tPA usage was not due to the expansion of the time window.

Study results also indicated more use of tPA to treat patients with less serious stroke symptoms, those ages 80 and older, and for black, Hispanic and other nonwhite patients.

"We expect that this expansion happened because, as providers get comfortable using this drug and seeing good patient outcomes, they become more willing to treat all eligible patients and not just those they feel are the 'cream of the crop’ for treatment," Schwamm said.

Schwamm, chair of the GWTG-S Clinical Workgroup, added that while hospitals choosing to join GWTG-S might be more likely than others to offer the most advanced stroke treatment, the program has grown to the point where many U.S. patients have access to a GWTG-S hospital.

Despite the expansion in tPA usage revealed by the study, Schwamm stressed that the drug remains underutilized: "We should be providing intravenous tPA to all eligible patients, which means that nearly a quarter of them are still missing that opportunity. Patients and their loved ones need to recognize the signs of a stroke and get to the hospital quickly by calling 911, and hospitals need to be ready to provide rapid diagnosis and treatment.

"We hope that our results will encourage more hospitals to join GWTG-S or similar stroke quality improvement programs to help accelerate their use of tPA. When patients learn that their local hospitals are treating stroke more aggressively, that can translate into more awareness and faster action by the public."

Study abstract: http://circoutcomes.ahajournals.org/content/early/2013/08/20/CIRCOUTCOMES.111.000095.abstract.


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