First10EM - June 07, 2021 - By Justin Morgenstern
“Bottom line
There are clearly varying interpretations of this literature. Considering the uncertainty in the data and the limitations of the individual trials, that makes sense to me. I think it is very reasonable that Dr. Drew suggests thrombolytics to his patients with acute ischemic stroke. Within the realm of uncertainty, a neurologic benefit is certainly possible. However, I personally think that appropriate critical appraisal of these articles suggests that the statistical benefit seen is probably primarily the result of a combination of bias and chance findings. I think that if we ever get the replication of NINDS that we so desperately need, it is more likely to be negative than positive. Of course, that is only an educated guess.
I hope that I properly characterized Dr. Drew’s thoughts throughout this rebuttal. If not, he has an open invitation to publish clarifications and rebuttals on this site. Again, the goal is not to shape clinical practice. This is not an issue that can be decided by rereading the same papers. We need replication studies to settle the debate. But while we wait for the appropriate science to be performed, our goal should be to ensure that both side’s arguments are being made as strongly as possible, and continue our discussion with the assumption that everyone involved wants the same thing: the best care for our patients.
Ultimately, I don’t actually care that much about the specific question of thrombolytics in acute ischemic stroke. I am not currently working in a stroke center, and even when I was, most patients weren’t eligible. On top of that, stroke makes up a tiny portion of all the emergency patients I see. Furthermore, I think the harms and benefits are likely very close based on the data we have seen so far, so whether you advise for or against thrombolytics, the difference is probably minimal. The reason I have spent so much time on this topic has nothing to do with the clinical management of stroke. The only reason I keep talking about this topic is that it provides us with insights into the workings of evidence based medicine, and the importance of reading papers and thinking critically rather than simply following guidelines.”