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Giving tPA to stroke patients within 6 hrs of symptom onset does not improve mortality or independence at 6 months.  However, patients might be a little “less disabled” while they are alive. Maybe.

Why It’s Important for Emergency Medicine

This is perhaps the most controversial article of 2012, call it thrombolytics-gate.  As the body of research on thrombolysis in acute stroke gets scrutinized closer, more and more ED physicians are questioning the purported benefits of tPA.  IST-3 is the biggest study of them all, enrolling over 3000 patients of all ages and stroke severities, but does little to clear up the confusion. See for yourself below…

Major Points

  • No difference in number of patients alive and independent @ 6 months
  • Patients who got tPA at < 3 hrs did well, between 3-4.5 hrs did worse, between 4.5-6 hrs did well again –  this randomness argues against time making a difference.
  • Secondary analysis suggests that though patients treated with tPA did not live longer or independently, they did survive with less disability.

Design & Results

  • Unblinded RCT, 3035 patients (age>80 years old = 53%)
  • 156 hospitals, 12 countries, 11 years

Criticisms

  • The evidence that treatment patients survived with less disability was found through ordinal analysis and statistical adjustment – whatever that means…
  • Only patients in whom the benefit of tPA was “uncertain” but “promising” were included.

Reviewed by V.Nguyen

MIA 2012 = Most Interesting Articles series of 2012

1.
IST-3 collaborative, Sandercock P, Wardlaw J, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet. 2012;379(9834):2352-2363. [PubMed]
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD

@M_Lin

Professor of Emerg Med at UCSF-Zuckerberg San Francisco General. Founder of ALiEM @aliemteam #PostitPearls https://t.co/7v7cgJqNEn
Michelle Lin, MD