Emergency Medicine Literature of Note - May 11, 2016 - Posted by Ryan Radecki
“Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial”
"Sometimes, medical practice in the setting of uncertainty simply turns out to be futile and low-value.
This is one of those times where we’ve probably been at least futile, and possibly harmful.
Life-threatening or critical intracranial bleeding in the setting of concomitant antiplatelet therapy frequently offers a dire prognosis. As part of our standard “don’t just stand there!” approach in Emergency Medicine, patients with ICH in this setting are frequently transfused platelets in an effort to provide untainted clotting substrate. This practice, however, has never been reinforced by substantiated evidence, and the pharmacokinetics of the antiplatelet agents suggests this strategy is unlikely to be efficacious...
This is the PATCH trial, a randomized, open-label trial conducted at 60 hospitals between 2009 and 2015, investigating the utility of platelet transfusion in the setting of ICH. Patients with normal baseline functional status and ICH while taking aspirin, clopidogrel, or dipyridamole were eligible for inclusion. Specific excluded ICH were epidural or subdural hematomas, significant intraventricular blood, surgical intervention planned, or those in which death appeared imminent. Treating clinicians could not be blinded to study arm allocation, but follow-up assessors and data analysis was masked. The primary outcome is was functional outcome on the modified Rankin Scale, analyzed via ordinal shift analysis...
In the end, outcomes were universally dismal. Only 15 patients in the entire study survived with minimal disability or better. The vast majority of patients were at least moderately disabled or dead at follow-up. And, while the confidence intervals for many of their comparisons cross unity, none of the trends favored platelet transfusion. Generally speaking, there were more deaths, fewer patients with minimal disability, and additional adverse events in the transfusion group.