Released with minimal fanfare, approved by the ACEP Board of Directors on June 24th, the revised ACEP Clinical Policy regarding the use of TPA for acute ischemic stroke has gone final.
It is, of course, a vast improvement over the 2012 version – but has, unfortunately, changed for the worse since the draft was posted.
The highlights:
- The Level A suggestion to consider the risk of ICH with tPA administration has been eliminated. It has been moved, nonsensically into the Level B recommendations for offering tPA – when, frankly, it’s the only consistent finding across all the evidence.
- The Level B recommendation in which tPA “may be given” within 3 hours has been strengthened to “should be offered and may be given”. Obviously, a profound difference.
- The Level B recommendation for 3-4.5 hours remains unchanged, based on only one flawed piece of Class II evidence (ECASS III), and conflicting Class III evidence (ATLANTIS, IST-3, meta-analyses).
- The Level C recommendation to engage in shared decision-making now states “when feasible”, which is obviously open to interpretation.
- No further clarification of “carefully selected patients” or “systems … in place to safely administer the medication” is provided.
Some wins, some losses. Obviously, the shared decision-making supporting any “offer” of tPA can be very different, depending on an individual clinicians’ interpretation of the evidence – and it is nice to see the prior COI-infested husk of rotten guidelines finally, officially, tossed on the compost heap. Let us hope (irrationally, of course) the efforts underway in the United Kingdom spur further, independent, investigation with which to better understand and individualize the risks and benefits of treatment with tPA.
“Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department”
http://www.acep.org/workarea/DownloadAsset.aspx?id=102373