A new development in the TPA debate as ACEP (American College of Emergency Physicians) has updated their policy regarding TPA use in stroke.
The draft policy can be viewed here in full, but let’s take a look at this:
“Patient Management Recommendations
Level A recommendations. The increased risk of symptomatic intracerebral hemorrhage (approximately 7% compared to a baseline of 1%) must be considered when deciding whether to administer IV tPA to acute ischemic stroke patients.
Level B recommendations. With a goal to improve functional outcomes, IV tPA may be given to carefully selected acute ischemic stroke patients within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication.
Level C recommendations. Shared decision-making between the patient (and/or their surrogate) and a member of the healthcare team must include a discussion of potential benefits and harms prior to the decision whether to administer IV tPA for acute ischemic stroke. (Consensus recommendation)
Potential Benefit of Implementing the Recommendations: Administration of IV tPA within 3 hours of stroke symptom onset increases the probability of better long-term functional outcome (NNT=6; 95% CI 4 to 110 when based on data from the Class I NINDS8 trials).
Potential Harm of Implementing the Recommendations: Administration of IV tPA within 3 hours of stroke symptom onset increases the risk of early sICH (NNH=17; 95% CI 12 to 34 when based on data from the Class I NINDS8 trials).
When considering administration of IV tPA for an acute ischemic stroke patient within 3 hours of stroke symptom onset, the physician and patient (and/or the surrogate), should weigh the potential benefit in terms of long-term functional outcome against the increased risk of sICH while recognizing that IV tPA does not alter 90-day mortality.”
(Level A: High degree of clinical certainty, Level B: Moderate degree of clinical certainty)
The old policy? Well, it placed “With a goal to improve functional outcomes, IV tPA may be given to carefully selected acute ischemic stroke patients within 3 hours after symptom onset at institutions where systems are in place to safely administer the medication.” as a Level A. The new policy grades it a Level B.
In a nutshell, the American College of Emergency Physicians just dropped TPA administration in Acute Stroke from being recommended with a high degree of clinical certainty to being recommended with a moderate degree a clinical certainty.
That’s certainly a bit of an uncertain departure from how certain they were 3 years ago.
The new policy change has been met with criticism as TPA defenders question the reasoning of the current ACEP leadership as being driven by fears of litigation and perhaps influenced by community physicians not confident in administering TPA.
