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Thrombolysis for Acute Stroke: Much Talk, Little Action
From 1999 to 2004, tPA was administered to only 1.2% of acute ischemic stroke patients in the U.S.
Myriad studies have demonstrated the effectiveness and safety of tissue plasminogen activator (tPA) when administered under the appropriate circumstances and its deleterious effects when administered improperly or in small, nonacademic, nonstroke-center hospitals without specific policies and procedures for its use. These studies have given rise to two vocal camps of emergency physicians — one for and one against use of tPA — largely split according to the type of center in which the EP practices.
To identify hospital and patient characteristics associated with administration of tPA, researchers analyzed data from the Nationwide Inpatient Sample for 1999 through 2004. Of nearly 370,000 patients with acute ischemic stroke who were admitted through an emergency department, 4104 (1.12%) received tPA (intravenously in 90.1% and intra-arterially in 9.9%). Most hospitals (69.5%) did not use tPA. Among hospitals that did use tPA, the mean number of patients treated with it annually per hospital was 3.06 (range, 1 to 76). Patient factors that significantly decreased the chances of a patient being treated with tPA were older age (odds ratio, 0.43 for patients 
85 compared with those <55), female sex (OR, 0.77), increased severity of illness (OR, 0.44 for patients with modified Charlson Index score 3 compared with those with score of 0), and black or Hispanic race/ethnicity (ORs, 0.54 and 0.79, respectively, compared with whites).
Comment: The database did not provide information about reasons for not giving tPA, other than presentation after the acceptable 3-hour window. The rate of tPA administration reported in this study is very low, with the hospitals divided mostly into those that rarely if ever use it and those that give it comparatively more often. The time has come for implementing systems of care that allow rapid screening and transport of eligible patients directly to centers that can safely administer tPA.
Published in Journal Watch Emergency Medicine August 24, 2007
Citation(s):
Schumacher HC et al. Use of thrombolysis in acute ischemic stroke: Analysis of the Nationwide Inpatient Sample 1999 to 2004. Ann Emerg Med 2007 Aug; 50:99-107.
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