{"id":3263,"date":"2015-06-29T15:00:00","date_gmt":"2015-06-29T15:00:00","guid":{"rendered":"http:\/\/www.emlitofnote.com\/?p=3263"},"modified":"2015-06-29T15:00:00","modified_gmt":"2015-06-29T15:00:00","slug":"the-new-improved-acep-clinical-policy-for-tpa-in-stroke","status":"publish","type":"post","link":"https:\/\/www.emlitofnote.com\/?p=3263","title":{"rendered":"The New, Improved, ACEP Clinical Policy for tPA in Stroke"},"content":{"rendered":"<p>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.<\/p>\n<p>It is, of course, a vast improvement over <a href=\"http:\/\/www.acep.org\/workarea\/DownloadAsset.aspx?id=91419\">the 2012 version<\/a> \u2013 but has, unfortunately, changed for the worse <a href=\"https:\/\/www.emlitofnote.com\/2015\/01\/the-wholesale-revision-of-aceps-tpa.html\">since the draft was posted<\/a>.<\/p>\n<p>The highlights:<\/p>\n<ul>\n<li>The Level A suggestion to consider the risk of ICH with tPA administration has been eliminated. &nbsp;It has been moved, nonsensically into the Level B recommendations for offering tPA \u2013 when, frankly, it\u2019s the only consistent finding across all the evidence.<\/li>\n<li>The Level B recommendation in which tPA \u201cmay be given\u201d within 3 hours has been strengthened to \u201cshould be offered and may be given\u201d. &nbsp;Obviously, a profound difference.<\/li>\n<li>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).<\/li>\n<li>The Level C recommendation to engage in shared decision-making now states \u201cwhen feasible\u201d, which is obviously open to interpretation.<\/li>\n<li>No further clarification of \u201ccarefully selected patients\u201d or \u201csystems \u2026 in place to safely administer the medication\u201d is provided.<\/li>\n<\/ul>\n<p>Some wins, some losses. &nbsp;Obviously, the shared decision-making supporting any \u201coffer\u201d of tPA can be very different, depending on an individual clinicians\u2019 interpretation of the evidence \u2013 and it is nice to see the prior COI-infested husk of rotten guidelines finally, officially, tossed on the compost heap. &nbsp;Let us hope (irrationally, of course)&nbsp;<a href=\"http:\/\/www.bbc.com\/news\/health-33127672\">the efforts underway in the United Kingdom<\/a> spur further, independent, investigation with which to better understand and individualize the risks and benefits of treatment with tPA.<\/p>\n<p>\u201cClinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department\u201d<br \/><a href=\"http:\/\/www.acep.org\/workarea\/DownloadAsset.aspx?id=102373\">http:\/\/www.acep.org\/workarea\/DownloadAsset.aspx?id=102373<\/a><\/p>\n\n<div class=\"twitter-share\"><a href=\"https:\/\/twitter.com\/intent\/tweet?via=emlitofnote\" class=\"twitter-share-button\">Tweet<\/a><\/div>\n","protected":false},"excerpt":{"rendered":"<p>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 \u2013 but has, unfortunately, changed for the worse since the draft was posted. &hellip; <a href=\"https:\/\/www.emlitofnote.com\/?p=3263\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &#8220;The New, Improved, ACEP Clinical Policy for tPA in Stroke&#8221;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2},"jetpack_post_was_ever_published":false},"categories":[23,14,15],"tags":[],"class_list":["post-3263","post","type-post","status-publish","format-standard","hentry","category-guidelines","category-neurology","category-stroke"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p7KesJ-QD","_links":{"self":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/posts\/3263","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3263"}],"version-history":[{"count":0,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/posts\/3263\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3263"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3263"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3263"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}