Time to Thrombolytics is FAster Better?
Salim Rezaie MD, Anand Swaminathan MD
- Since the publication of the NINDS study in 1994, the idea that “time is brain” has been imprinted into our collective psyche.
- Over the last 26 years, numerous systems have been developed to deliver thrombolytics faster to patients with presumed ischemic strokes.
- Clinical Questions:
- Is faster better? Does it matter if the patient gets thrombolytics at 30 minutes in comparison to 60 minutes? What cost does faster come with?
- Potential costs of pushing for faster thrombolytic delivery
- Determining whether the patient is having an ischemic stroke or a stroke mimic can take time in some cases.
- It takes time to weigh the risks and benefits of alteplase and to discuss this with the patient in order to facilitate shared decision making.
- Resources are finite. If we dedicate more resources to delivering alteplase faster, there will be less resources for other time sensitive conditions (eg, STEMI, sepsis)
- Misidentifying and mistreating cases can lead to harm
PERSPECTIVES
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- Fanari Z et al. Aggressive Measures to Decrease “Door to Balloon” Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement. Mayo Clin Proc. 2015 PMID: 26549506
- Avoiding thrombolytic administration in stroke mimics
- This is very challenging but important, as there is no benefit and only potential harm in these cases.
- There is a 2% rate of intracerebral hemorrhage following thrombolytic administration in patients with stroke mimics.
- Angioedema is another serious side effect.
- It is unlikely that we can eliminate thrombolytic administration in all stroke mimics based on current diagnostic limitations.
PERSPECTIVES
- Man S et al. Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients with Acute Ischemic Stroke. JAMA 2020; 323(21): 2170-84. DOI: 10.1001/jama.2020.5697
- Retrospective study of > 60,000 patients
- The authors conclude that faster administration is better but, there are numerous issues with their data:
- The group receiving alteplase later were sicker at baseline with more comorbid conditions.
- It is unclear why patients who received alteplase later - was it due to a diagnostic challenge?
- The early administration group includes more stroke mimics and TIAs - patients who would get better regardless.*
- What should we be doing clinically to reduce harm?
- Don’t rush and cut corners - do a thorough evaluation to determine first if the patient is having an ischemic stroke and secondary, whether they will benefit from alteplase.
- Take a thorough history to try to eliminate stroke mimics.
- Take time to review the inclusion and exclusion criteria in each case.
- Take the time to discuss goals of care and values with the patient and/or family.
Chad M. - March 3, 2021 12:20 PM
I liked the recent segment on time to thrombolytics in the February emrap. Our facility is likely switching to tenectaplase given the recent trials showing better reperfusion before thrombectomy. I think we're going to use it for regular strokes as well, and I'm having trouble finding clear evidence for this. I have found papers describing non inferiority of tnk to alteplase, but I think the evidence for alteplase is pretty weak as it is! Is tnk better supported on its own vs placebo for acute ischemic stroke?