1. Edward P. Sloan, MD, MPH FERNE/EMRA Session: Treating Ischemic Stroke Patients Using a 3 to 4.5 Hour tPA Window

2. Edward P. Sloan, MD, MPH Boston, MA October 6, 2009 2009 ACEP Scientific Assembly & EMRA Semi-Annual Meetings Boston, MA October 6, 2009

3. Edward P. Sloan, MD, MPH, FACEP Edward P. Sloan, MD, MPH Professor Department of Emergency Medicine University of Illinois at Chicago Chicago, Illinois

4. Edward P. Sloan, MD, MPH, FACEP Attending Physician Emergency Medicine University of Illinois Hospital Swedish American Belvidere Hospital Chicago, IL

5. Edward P. Sloan, MD, MPH, FACEP Disclosures FERNE Chairman and President FERNE grants by industry Participation on industry-sponsored advisory boards and as lecturer in programs supported by industry ACEP Clinical Policy Committee 2009 EMRA at ACEP Educational activities supported by unrestricted Educational Grants from Genentech, EKR Therapeutics, Inc., and The Medicines Company No specific disclosures related to this topic.

6. Edward P. Sloan, MD, MPH, FACEP www.ferne.org

7. Personal Experience 10 years, ~20 lectures Re: tPA use10 years, ~20 lectures Re: tPA use Preparing clinicians for optimal care of ischemic stroke patientsPreparing clinicians for optimal care of ischemic stroke patients Explaining the standard of care as seen by patients and societyExplaining the standard of care as seen by patients and society Participation in medico-legal casesParticipation in medico-legal cases Awareness of both perspectivesAwareness of both perspectives

8. Edward P. Sloan, MD, MPH, FACEP The Initial tPA Data

9. Edward P. Sloan, MD, MPH, FACEP

11. Responses by Our Medical Societies

12. Edward P. Sloan, MD, MPH, FACEP

18. tPA 3-4.5 Hour Data

19. Edward P. Sloan, MD, MPH, FACEP

21. Recent Responses

22. Edward P. Sloan, MD, MPH, FACEP

28. tPA Use Facts tPA has been shown to be effectivetPA has been shown to be effective tPA can be used clinically with success in the care of stroke patientstPA can be used clinically with success in the care of stroke patients Patients and society expect tPA usePatients and society expect tPA use Clinicians remain divided Re: tPA useClinicians remain divided Re: tPA use The ASA has now forced our handsThe ASA has now forced our hands We must lead efforts Re: use of tPA in the 3-4.5 hour windowWe must lead efforts Re: use of tPA in the 3-4.5 hour window

29. Edward P. Sloan, MD, MPH, FACEP This Educational Session This introduction and perspectiveThis introduction and perspective E Bradshaw Bunney, MD: The 3-4.5 hour window tPA dataE Bradshaw Bunney, MD: The 3-4.5 hour window tPA data Panel discussion:Panel discussion: What do we think?What do we think? What should we do in our systems?What should we do in our systems? What are the best clinical options?What are the best clinical options?

30. Edward P. Sloan, MD, MPH, FACEP Panel Discussion Yu-Feng Yvonne Chan, MDYu-Feng Yvonne Chan, MD Mt Sinai, NY, NYMt Sinai, NY, NY SAEM Neuro Interest GroupSAEM Neuro Interest Group E Bradshaw Bunney, MDE Bradshaw Bunney, MD Univ Illinois, Chicago, ILUniv Illinois, Chicago, IL FERNEFERNE Residency DirectorResidency Director Get with the GuidelinesGet with the Guidelines

31. Edward P. Sloan, MD, MPH, FACEP Panel Discussion Jonathan Edlow, MDJonathan Edlow, MD Beth Israel Hospital, Boston, MABeth Israel Hospital, Boston, MA FERNEFERNE Neurological EmergenciesNeurological Emergencies Richard Shih, MDRichard Shih, MD Morristown Memorial Hospital, NJMorristown Memorial Hospital, NJ Residency DirectorResidency Director MEMC V Scientific ChairMEMC V Scientific Chair

32. Edward P. Sloan, MD, MPH, FACEP Clinical Questions Is the 3-4.5 hour window data adequately supportive of the ASA recommendation Re: tPA use?Is the 3-4.5 hour window data adequately supportive of the ASA recommendation Re: tPA use? Will it be possible for clinicians to replicate the ECASS 3 outcomes?Will it be possible for clinicians to replicate the ECASS 3 outcomes?

33. Edward P. Sloan, MD, MPH, FACEP Systems Questions What must be done in our institutions in order to implement the ASA recommendations?What must be done in our institutions in order to implement the ASA recommendations? What are some unique approaches to the use of tPA in the 3 -4.5 hour window?What are some unique approaches to the use of tPA in the 3 -4.5 hour window? How should we continue to educate in order to optimize stroke patient care and EM clinical practice?How should we continue to educate in order to optimize stroke patient care and EM clinical practice?

34. Edward P. Sloan, MD, MPH, FACEP Unanswered Questions Up to 3 hours: tPA first, then interventional radiology techniquesUp to 3 hours: tPA first, then interventional radiology techniques In the 3 -4.5 hour window, what is the best approach?In the 3 -4.5 hour window, what is the best approach? Has anything changed significantly?Has anything changed significantly? Where do we go from here?Where do we go from here?

35. Edward P. Sloan, MD, MPH, FACEP Conclusions Important disease stateImportant disease state Patients and clinicians care about the use of tPA in optimizing outcomesPatients and clinicians care about the use of tPA in optimizing outcomes This is an evolving processThis is an evolving process FERNE continues to educateFERNE continues to educate Clinicians continue to clarify practiceClinicians continue to clarify practice Systems continue to adapt to needsSystems continue to adapt to needs

36. Edward P. Sloan, MD, MPH, FACEP Questions? www.FERNE.org edsloan@uic.edu ferne_emra_acep_2009_sloan_stroke_intro_100609_final 4/30/2015 8:32 AM