News:Acute ischemic stroke: a decade of education and clinical investigation isn’t enough
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August 16, 2007 By Grendel Burrell [1]
In 2001, the United States Congress established the Paul Coverdell National Acute Stroke Registry to measure and track the quality of care provided to acute stroke patients.(1) In order to assess prehospital delays from onset of stroke symptoms to ED arrival and hospital delays from ED arrival to receipt of brain imaging, the CDC analyzed data from the four states (Georgia, Illinois, Massachusetts, and North Carolina) participating in the national stroke registry. The results of that analysis were presented in the May 18, 2007, MMWR Weekly (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5619a3.htm) and discussed in the August 13 Los Angeles Times.
Each year approximately 700,000 persons in the United States have a new or recurrent stroke. 15-30% become permanently disabled, and 20% require institutionalization during the first 3 months after the stroke (2). The severity of stroke-related disability can be reduced if timely and appropriate treatment is received (3). Patients with acute ischemic stroke may be eligible for treatment with intravenous recombinant t-PA if therapy can be initiated within 3 hours of symptom onset (4).
Receipt of prompt treatment requires the patient, the family, friend, or coworker to recognize stroke symptoms. The suspected stroke patient should be rapidly transported by EMS to a hospital emergency department (ED), where the systems are in place for timely evaluation, including computed tomography or magnetic resonance imaging, and where treatment for eligible patients can occur. The only FDA approved therapy for acute ischemic stroke is recombinant t-PA (Activase®). For patients eligible for t-PA, evidence suggests that the earlier patients are treated after the onset of symptoms the greater the likelihood of a more favorable outcome (5).
More than a decade after the approval of t-PA for the treatment of acute stroke, and after millions of dollars spent on public awareness and education on the signs and symptoms of acute stroke, 48.0% of stroke patients for whom onset data were available in the CDC study arrived at the ED within 2 hours of symptom onset. Prehospital delays were shorter for persons transported to the ED by ambulance than for persons who were transported by friends and family; however, only 53.4% of patients arrived by ambulance. The interval between ED arrival and brain imaging also was significantly reduced for those arriving by ambulance. The findings also demonstrated that a greater proportion of blacks compared with whites, had longer prehospital delay times. Further studies regarding the use of ambulances by stroke patients in minority populations are needed to determine culturally effective interventions to increase the use of ambulances to promote better access to appropriate care. Clearly, more extensive public education is needed regarding early recognition of stroke and the urgency of telephoning 911 to receive ambulance transport.
17,643 patients were included in the study, 53.3% were women, 75.8% were white, 19.6% were black, and 2.7% were Hispanic 66.1% of patients were >65 years. Among these patients, women were older than men (mean age: 72.0 versus 67.7 years, p<0.001), and whites were older than blacks (mean age: 72.2 versus 62.4 years, p<0.001). Ischemic stroke (65.1%) was the most common stroke subtype, followed by transient ischemic attack (24.0%) and hemorrhagic stroke (9.7%) (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5619a3.htm).
Shortening prehospital and hospital delays will increase the proportion of ischemic stroke patients who are eligible to receive t-PA therapy and reduce their risk for severe disability from stroke assuming they arrive at a hospital willing and prepared to treat acute stroke patients. For ischemic stroke patients to benefit from intravenous t-PA therapy, therapy should begin as soon as possible after diagnosis and determination of eligibility and must be initiated within 3 hours of symptom onset (6).
But patient transport isn’t the only delay to treatment for acute stroke. Clearly, many patients arrive within three hours of symptom onset. Some patients have contraindications to therapy, but even after a decade of experience with t-PA, many physicians haven’t embraced this therapy. Dr. Valerie Ulene, writing for the Los Angeles Times on August 13, 2007 (http://www.latimes.com/features/health/la-he-themd13aug13,1,4493373.story), details the current approach of the American Academy of Emergency Physicians: “In a survey of 1,000 emergency room physicians conducted in 2004, 40% reported that they were not likely to use tPA, even under ideal conditions. Officially, the American College of Emergency Physicians (ACEP) does not support t-PA as the standard of care for strokes (acute ischemic type). The organization points to the drug's potentially serious side effects, particularly bleeding into the brain, and calls into question the studies that have shown the drug to be effective.” The official position of ACEP on the treatment of acute stroke with t-PA can be found at http://www.acep.org/webportal/PracticeResources/PolicyStatements/pracmgt/UseofIntravenoustPAforAcuteStroke.htm.
WikiDoc queried Edward Jauch, MD, MS, Associate Director of Research, Department of Emergency Medicine, University of Cincinnati, about the current, official stance of ACEP on the use of t-PA for treatment of acute stroke. Jauch, one of the authors of the American Heart Association’s and American Stroke Association’s Guidelines for the Early Management of Adults With Ischemic Stroke (6), stated “The new guidelines deliberately attempted to engage the emergency medicine community. Not only were two emergency medicine physicians co-authors on the guidelines but the recommendations acknowledge the importance of developing multidisciplinary acute stroke care teams, starting in the pre-hospital setting with EMS and incorporating all health care professionals involved in the stroke patient’s acute evaluation and treatment. By developing integrated EMS triage policies with stroke teams and committed hospitals prepared to care for acute stroke patients, more stroke patients will be positioned to receive optimal care, including thrombolytics when appropriate. ACEP, the American Academy of Neurology, and the American Heart Association/American Stroke Association are currently collaborating on the evaluation of best practices in the diagnosis and management of acute ischemic stroke.”
The publication of these updated guidelines include, for the first time, recommendations for emergency medical services to use brief stroke identification algorithms--such as the Los Angeles Prehospital Stroke Screen or the Cincinnati Prehospital Stroke Scale--to rapidly initiate stroke management in the field with pre-established stroke protocols. Additionally and importantly, the new guidelines encourage EMS to transport patients to centers where there are adequate treatment resources. Jauch said that he expects “these changes will improve access to institutions prepared to rapidly diagnose and treat eligible patients with the most current and effective therapies available.” Jauch went on to say “The guidelines encourage the emergency department to be part of the treatment approach in partnership with local stroke teams. The guideline authors are not asking emergency physicians to act alone, rather they are asking emergency medicine to actively participate in a team approach to improving outcomes for these patients.”
The Brain Attack Coalition (BAC) has proposed designation of certain hospitals as Primary Stroke Services facilities organized to stabilize and provide emergency care for patients with acute stroke (7). BAC recommends the coordination of ambulance services with EDs of Primary Stroke Services facilities and that this should be an integral component of the approach to ensure rapid evaluation and transport of acute stroke patients to appropriate facilities (8). Use of coordinated ambulance services that include advance notification to receiving hospitals can increase opportunities for receipt of t-PA among those with ischemic stroke.
Coordinated efforts to improve time to the diagnosis and treatment of acute ischemic stroke are needed. Physicians, emergency medical systems, and hospitals must coordinate care and increase access to approved therapies for eligible acute stroke patients. Patients and the public must not ignore symptoms of acute stroke. They must learn to recognize the signs and symptoms and to immediately access emergency medical transport systems.
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Resources for patients:
www.ninds.nih.gov/disorders/stroke/stroke.htm
www.americanheart.org/ presenter.jhtml?identifier=3000333
http://www.gene.com/gene/products/information/cardiovascular/activase/index.jsp
What is Stroke? A stroke occurs when the blood supply to part of the brain is suddenly interrupted or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells. Brain cells die when they no longer receive oxygen and nutrients from the blood or there is sudden bleeding into or around the brain. The symptoms of a stroke include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss of balance or coordination; or sudden severe headache with no known cause. There are two forms of stroke: ischemic - blockage of a blood vessel supplying the brain, and hemorrhagic - bleeding into or around the brain. (www.ninds.nih.gov/disorders/stroke/stroke.htm)
Stroke is the number one cause of adult disability in America, with more than three million people living with the effects of stroke and more than one million severely impaired. About 80 percent of all strokes are acute ischemic strokes caused by a blood clot stopping or diminishing blood flow to an area of the brain. Thus, acute ischemic stroke, or "brain attack," has comparable physiological cause as an acute myocardial infarction, or heart attack. (http://www.gene.com/gene/products/information/cardiovascular/activase/index.jsp)
What is the prognosis? Although stroke is a disease of the brain, it can affect the entire body. A common disability that results from stroke is complete paralysis on one side of the body, called hemiplegia. A related disability that is not as debilitating as paralysis is one-sided weakness or hemiparesis. Stroke may cause problems with thinking, awareness, attention, learning, judgment, and memory. Stroke survivors often have problems understanding or forming speech. A stroke can lead to emotional problems. Stroke patients may have difficulty controlling their emotions or may express inappropriate emotions. Many stroke patients experience depression. Stroke survivors may also have numbness or strange sensations. The pain is often worse in the hands and feet and is made worse by movement and temperature changes, especially cold temperatures. Recurrent stroke is frequent; about 25 percent of people who recover from their first stroke will have another stroke within 5 years. (www.ninds.nih.gov/disorders/stroke/stroke.htm)
