Richard Shih, MD, FACEP Stroke Patient Management Using IV tPA: When and How Should It Be Utilized in ED Patients?

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Presentation transcript:

Richard Shih, MD, FACEP Stroke Patient Management Using IV tPA: When and How Should It Be Utilized in ED Patients?

Richard Shih, MD, FACEP Emergency Medicine Associates Atlantic City, NJ September 26-27, 2006

Richard Shih, MD, FACEP 2006 Advanced Emergency & Acute Care Medicine and Technology Conference 2006 Advanced Emergency & Acute Care Medicine and Technology Conference

Richard Shih, MD, FACEP Richard Shih, MD, FACEP Program Director Department of Emergency Medicine Morristown Memorial Hospital, Morristown, NJ

Richard Shih, MD, FACEP Disclosures All past advisory board or speakers’ bureau activities have expired within the past year All past advisory board or speakers’ bureau activities have expired within the past year

Richard Shih, MD, FACEP Sessions Objectives Discuss the NINDS study results Discuss the NINDS study results Discuss the Follow-up studies to NINDS Discuss the Follow-up studies to NINDS Discuss the NINDS reanalysis Discuss the NINDS reanalysis

Richard Shih, MD, FACEP Case Presentation… 55 yo M presents to ED Weakness on his left side “Couldn’t grasp cup of coffee or key” Symptoms began 30 minutes Hx NIDDM, smoker No recent illness

Richard Shih, MD, FACEP Give TPA? Code Grey Code Grey Radiology resident read of CT Radiology resident read of CT Stat Neurology consult? Stat Neurology consult? Standard of care? Standard of care? Medicolegal risk? Medicolegal risk?

Richard Shih, MD, FACEP

The NINDS Study TPA works for acute stroke!! TPA works for acute stroke!! TPA causes IC bleed TPA causes IC bleed 3 hour window: TIA or stroke mimic 3 hour window: TIA or stroke mimic NINDS:only (+) study NINDS:only (+) study only enrolled 624 patients sicker pts in placebo group

Richard Shih, MD, FACEP Thrombolytic Clinical Trials Initial IV streptokinase studies failed: MAST-E (Europe), MAST-1 (Italy), ASK (Australia): Initial IV streptokinase studies failed: MAST-E (Europe), MAST-1 (Italy), ASK (Australia): (-) benefit; [6 hr window] (-) benefit; [6 hr window] Initial IV TPA trial: ECASS (Europe): Initial IV TPA trial: ECASS (Europe): (-) benefit. However, selected subgroups may benefit; [6 hr window] (-) benefit. However, selected subgroups may benefit; [6 hr window] Next IV TPA trial: NINDS (US): Next IV TPA trial: NINDS (US): (+) benefit; [dose finding & 3 hr window] (+) benefit; [dose finding & 3 hr window]

Richard Shih, MD, FACEP The NINDS Study 3 hr treatment window 3 hr treatment window TPA dose: 0.9 mg/kg (max 90 mg) TPA dose: 0.9 mg/kg (max 90 mg) 10%: bolus 10%: bolus 90%:IV infusion over 1 hr 90%:IV infusion over 1 hr TPA patients with 30% greater chance for minimal or no disability (at 3 mo) TPA patients with 30% greater chance for minimal or no disability (at 3 mo) Increased IC bleed risk (0.6 vs 6.4%) Increased IC bleed risk (0.6 vs 6.4%)

Richard Shih, MD, FACEP NINDS Follow-up Studies NINDS (+) at 1 yr follow-up NINDS (+) at 1 yr follow-up Other follow-ups studies: Other follow-ups studies: STARS study: JAMA 2000 STARS study: JAMA 2000 Cleveland experience: JAMA 2000 Cleveland experience: JAMA 2000 Trouillas et al: Stroke 1998 Trouillas et al: Stroke 1998 Buchan et al: Neurology 2000 Buchan et al: Neurology 2000 Grond et al: Stroke 1998 Grond et al: Stroke 1998 Chiu et al: Stroke 1998 Chiu et al: Stroke 1998 TPA stroke survey group: Neurology 1999 TPA stroke survey group: Neurology 1999 Oregon Experience: J Stroke Cerebrovasc Dis 1999 Oregon Experience: J Stroke Cerebrovasc Dis 1999 Wirkowski et al: J Stroke Cerebrovasc Dis 1999 Wirkowski et al: J Stroke Cerebrovasc Dis 1999

Richard Shih, MD, FACEP Pooled Analysis Hacke et al: Lancet 2004 Hacke et al: Lancet 2004 Graham GD: Stroke 2003 Graham GD: Stroke 2003 IC bleed is the main risk IC bleed is the main risk Risk at ~ 5.2% Risk at ~ 5.2%

Richard Shih, MD, FACEP

NINDS Reanalysis Subgroup patient assignment Subgroup patient assignment minute treatment arm (worse Px) minute treatment arm (worse Px) Placebo group had sicker patients in this are (NIHSS < 5: 19 vs 4%) Placebo group had sicker patients in this are (NIHSS < 5: 19 vs 4%) Study results reaffirmed Study results reaffirmed

Richard Shih, MD, FACEPConclusions TPA for CVA data support its use in selected patients NINDS study data has been debated thoroughly

Richard Shih, MD, FACEP Questions? ferne_ema_2006_shih_tpa3hour_092606_finalcd 2/8/ :05 PM