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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Friday, July 24, 2015

tPA-AVC isquémico (ACEP 2015): nivel B

MEDEST - 24 Lug 2015
On June 2015 ACEP updated the 2013 policy on ischemic stroke treatment.
"Here is the most relevant changes:
  • TPA administration within 3 hours was graded as a Level B recommendation (NNT 8 with a 95% CI).
  • The statement says that tPA “should be offered and may be given to selected patients” (“should be offered” alone in 2013 policy) 
  • In the same Level B recommendation was incorporated consideration (that in the previously Jan Draft was Level A) about sICH risk (7% with a NNH of 17 and 95%CI).
  • TPA administration between 3 and 4.5 hours is still considered a Level B recommendation (NNT=14; 95% CI). The the risk of early sICH in this case correspond to a NNH of 23 (95% CI)
  • The recommendation statement begins mentioning and prioritizing the“known risk of sICH and the variability in the degree of benefit in functional outcomes”, and about tPA treatment says “may be given to carefully selected patients” (“should be considered” in in 2013 policy)
Bottom line:
I think thrombolysis is a beneficial treatment for a selected group of patients. The available evidences and policies (even this last one) based on time window alone, and not patient centered, don’t clearly indicate which group of patients really benefits from tPA administration.
This 2015 ACEP policy suggests physician to strongly consider the risk (evident)/benefit (maybe) ratio when offering tPA in acute ischemic stroke and to strongly involve patients in the final decision. It also leave the clinician a wide range of choice to decide which is the right patient to treat with tPA."

“When considering administration of IV tPA for a patient with acute ischemic stroke within 3 hours of stroke symptom onset, the physician and patient (and/or the surrogate) should weigh the potential benefit in terms of long-term functional outcome against the increased risk of sICH while recognizing that IV tPA does not alter 90-day mortality.“