Tuesday, September 16, 2008

Thirteen years after the NINDS trial

---we still can’t agree on TPA.

From Emergency Medicine News:

The results of the National Institute of Neurological Disorders and Stroke (NINDS) trial on tissue plasminogen activator were published in 1995, and since then it's been lauded as a landmark study time and again by almost everyone but emergency physicians. (N Engl J Med 1995; 333[24]:1581.) The most recent American Heart Association (AHA) guidelines, supported by the American Academy of Neurology (AAN), recommend intravenous rtPA for selected patients within three hours of ischemic stroke onset. (Stroke 2007;38[5]:1655.)………

From an emergency medicine perspective, the American Academy of Emergency Medicine and the Society of Academic Emergency Medicine unequivocally state that tPA is not standard of care due to insufficient evidence concerning risk and benefit. The American College of Emergency Physicians' position statement also cites insufficient evidence for tPA as standard of care when systems are not in place to ensure that inclusion/exclusion criteria…are followed. ACEP is currently reviewing its clinical policy on stroke, but it won't be finalized until the end of this year or early 2009.

W. Richard Bukata, MD, a clinical professor of emergency medicine at Los Angeles County-USC Medical Center, is quick to point out the discrepancy between the medical groups. So what we have, honestly, is a disagreement between all the emergency physician organizations and the American Heart Association and the American Academy of Neurology, he said.

So 13 years after NINDS, we’re still fighting, despite more recent evidence from community experience validating the use of TPA.

1 comment:

PharmacistMike said...

The fears over TPA, getting sued if the patient bleeds and sued if you don't use it, are overwhelming and may cause most physicians to look for contraindications for use instead following the data and increasing it's use.