People having an ischemic stroke should receive clot-dissolving therapy if appropriate within 60 minutes of arriving at the hospital, according to new guidelines from the American Stroke Association.
During an acute stroke, physicians must evaluate and diagnose the patient as soon as possible to determine eligibility to receive recombinant tissue plasminogen activator, which must be given 4.5 hours within hours of symptom onset. The goal is to minimize “door to needle” time to an hour or less if possible, thereby giving the patient the best chance to benefit from the treatment.
Still, Edward Jauch, MD, the lead author of the guidelines and director of the Division of Emergency Medicine at the Medical University of South Carolina, said in a news release: “tPA can now be considered for a larger group of patients, including some who present up to 4.5 hours from stroke onset.”
The new guidelines recommend integrating regional networks of comprehensive stroke centers (which offer 24/7, highly specialized treatment for all types of stroke); primary stroke centers (which provide 24/7 specialized care mainly for ischemic stroke); acute stroke-ready hospitals (which can evaluate and treat most strokes but lack highly specialized capabilities); and community hospitals.
“This is the first time weve brought these healthcare elements together — including community hospitals, which may lack onsite stroke expertise — which reflects the emerging roles of telemedicine in these hospitals,” Jauch said.
Among other major revisions to the guidelines, if feasible, patients should be rapidly transferred to the closest available certified primary care stroke center or comprehensive stroke center, which might involve air medical transport.
“However, for patients brought to hospitals without specialized stroke expertise, telemedicine can provide real-time access to expertise,” Jauch said. “If such a hospital partners with a primary or comprehensive stroke center and uses telemedicine, early treatment decisions can be made for patients. If the patient had to be transferred before administering some therapies, it would be too late.”
Among other key recommendations in the new guidelines, multidisciplinary quality improvement committees should be created within hospitals to review and monitor stroke care quality. “We have dozens of studies showing the benefit of QI programs,” Jauch said.
Recently introduced stent retrievers might remove large blood clots more completely and quickly than tPA. But the devices should not be a substitute for intravenous tPA and should be used only in clinical studies to determine whether they improve patient outcomes.
The guidelines are scheduled for publication in Stroke, a journal of the American Heart Association/American Stroke Association, and are available at http://stroke.ahajournals.org/content/early/2013/01/31/STR.0b013e318284056a.full.