Article of the Week

Article of the Week: tPA

This more a clinical policy than a paper. It’s the recently released ACEP Clinical Policy on TPA.
About two years ago, our residency held a journal club to discuss the ACEP 2013 clinical policy on TPA and the studies that led up to it. Several residents noted during that journal club that they were surprised that ACEP gave a Level A Recommendation for the use of TPA when only a few studies (notably NINDS) supported this recommendation.
Fast forward two years and ACEP has now revised it’s policy and there are some notable changes.

TPA is no longer a Level A recommendation, it’s now Level B and states that it “should be offered and may be given” for suspected ischemic stroke within 3 hours. The language used for 3-4.5 hours has also be revised.

Lastly, the new clinical policy also discusses incorporating “shared decision making” with the patient/family regarding potential risks/benefits, most notably spontaneous intracerebral hemorrhage. I’ve included the 2013 and the 2015 version for your reading pleasure.
  1. 2013
    American College of Emergency Physicians; American Academy of Neurology. Clinical Policy: Use of intravenous tPA for the management of acute ischemic stroke in the emergency department. Ann Emerg Med. 2013 Feb;61(2):225-43. doi: 10.1016/j.annemergmed.2012.11.005.
    http://www.annemergmed.com/article/S0196-0644(12)01736-2/pdf

  2. 2015
    American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Use of Intravenous tPA for Ischemic Stroke:, Brown MD, Burton JH, Nazarian DJ, Promes SB. Clinical Policy: Use of Intravenous Tissue Plasminogen Activator for the Management of Acute Ischemic Stroke in the Emergency Department. Ann Emerg Med. 2015 Sep;66(3):322-333.e31. doi: 10.1016/j.annemergmed.2015.06.031.
    http://www.annemergmed.com/article/S0196-0644(15)00576-4/pdf
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