If you're still skeptical about the use of tPA in stroke patients – too bad. If you're not on the bus, it would seem now you're under it. ACEP has published their new Clinical Policy regarding tPA use in the most recent issue of Annals of Emergency Medicine. tPA should be offered to folks in the 0-3 hour window who meet NINDS criteria as a Level A recommendation. This is based on the following Class I evidence:
- Two studies that are negative for benefit (ECASS, ATLANTIS)
- The post-hoc analysis of ATLANTIS B with 61 patients,
If you'll travel backwards in time a couple days (by scrolling down), you'll see I did a quick review of two articles concerning the "trustworthiness" of clinical practice guidelines. The Institute of Medicine names eight criteria – and, for the most part, this guideline does OK. It does, unfortunately, fare less well at the conflict of interests declared:
- Dr. Smith – Served on scientific advisory board for Genentech.
- Dr. Gronseth – Speakers' bureau for, and honoraria from, Boehringer Ingelheim.
- Dr. Messe – Former speakers' bureau for Boehringer Ingelheim.
If you're irritated that pharmaceutical manufacturers are helping write our clinical guidelines, make your voice heard.
"Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department"