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New Acute Stroke Guidelines promote organized systems of care, broader use of intravenous fibrinolysis and caution with new anticoagulants and endovascular interventions

Susan C. Fagan, Pharm.D., FCCP, BCPS
Jowdy Professor and Assistant Dean
University of Georgia College of Pharmacy
March, 2013

After almost 6 years of waiting, the American Heart Association / American Stroke Association have finally published new evidence-based guidelines for the early management of patients with acute ischemic stroke.1

Although most of the recommendations are exactly or mostly the same as in the 2007 version or in published updates, the new guidelines reflect the endorsement of designated stroke centers and the vast experience with intravenous tissue plasminogen activator (tPA) since its approval by the FDA in 1996. The initial guidelines for the use of tPA were very strict regarding comorbid conditions and adherence to the protocol followed in the pivotal clinical trials. The ensuing decades of experience have resulted in a recalibration of the risk and a reduction in the restrictions. In addition, the document addresses the impact of the newer oral anticoagulants on the decision to treat with tPA and recommends a conservative approach to the use of endovascular interventions in the acute ischemic stroke patient.

The key evidence-based (or lack thereof) recommendations from the 2013 guidelines include:

  1. An organized approach to prehospital care that includes use of emergency transport to centers with documented expertise in stroke care.
  2. Use of telestroke systems to assist sites in making timely decisions to use intravenous tPA.
  3. Limiting the number of laboratory and other tests ABSOLUTELY needed prior to initiation of intravenous tPA to serum glucose only.
  4. A door-to-needle time of within 60 minutes from hospital arrival for the use of tPA.
  5. A consideration for use of tPA in previously excluded patient groups: mild symptoms, rapidly improving, major surgery in past 3 months or recent myocardial infarction, after weighing risks versus benefits.
  6. A recommendation AGAINST use of tPA in patients receiving the newer oral anticoagulants UNLESS able to document NORMAL coagulation status OR OFF the drug for at least 2 days prior to stroke.
  7. A recommendation of intravenous tPA over any intraarterial or endovascular intervention.
  8. A recommendation for initiation of oral aspirin therapy 325 mg within 24 to 48 hours of stroke onset for most patients.
  9. A cautious approach to the use of endovascular interventions, probably in further clinical trials, to document improved patient outcomes.

Reference:

Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2013; epub ahead of print, January 31

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Saturday, November 01, 2014