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The tPA recommendation on the NNT website changed to "the net benefit & harms are unclear due to uncertainty of data" authored by @TheSGEM
I believe it's helpful to clarify a few points on this debate so we present families with correct info before they make a decision on tPA. https://twitter.com/TheSGEM/status/1388546277797994499
I believe it's helpful to clarify a few points on this debate so we present families with correct info before they make a decision on tPA. https://twitter.com/TheSGEM/status/1388546277797994499
1. The main source for the recommendation is from a review paper in Emerg Med Australasia (see below).
This paper includes all thrombolytics (anistreplase, streptodornase, streptokinase, urokinase, lumbrokinase, duteplase, lanoteplase, pamiteplase, etc) https://pubmed.ncbi.nlm.nih.gov/27561375/
This paper includes all thrombolytics (anistreplase, streptodornase, streptokinase, urokinase, lumbrokinase, duteplase, lanoteplase, pamiteplase, etc) https://pubmed.ncbi.nlm.nih.gov/27561375/
Clumping the data to include all thrombolytics is not helpful, as only alteplase (tPA) is clinically used. We have moved on from the old thrombolytics.
When studying the new thrombolytic Tenecteplase in a RCT, we will not compare it to streptokinase. Thats not helpful.
When studying the new thrombolytic Tenecteplase in a RCT, we will not compare it to streptokinase. Thats not helpful.
2. We already have a meta-analysis from 1,549 patients enrolled from 7 RCTs demonstrating a clear time-dependent effect of increasing the probability of a good outcome with tPA.
See Emberson et al. paper below. https://pubmed.ncbi.nlm.nih.gov/25106063/
See Emberson et al. paper below. https://pubmed.ncbi.nlm.nih.gov/25106063/
Skeptics will say that the IST-3 study included in the above meta-analysis has selection bias in the 3-4.5hr window.
However, 1) it meets eligibility to be included in a systematic review & 2) if excluded, would only strengthen the effect for tPA during this time window.
However, 1) it meets eligibility to be included in a systematic review & 2) if excluded, would only strengthen the effect for tPA during this time window.
3. Skeptics will say that we are treating more stroke mimics (i.e. TIA) early on in the treatment window, that would have clinically improved irrespective of treatment.
Counter to this argument below
Counter to this argument below
1) We are better at excluding mimics with our advanced imaging techniques (CTA/CTP) (many clinical events thought to be TIAs are in fact small ischemic strokes)
2) We have data to show that thrombolysing a mimic carries very little to no risk given there is no infarcted tissue
2) We have data to show that thrombolysing a mimic carries very little to no risk given there is no infarcted tissue
I believe this debate is past healthy skepticism.
The burden of proof lies with those skeptical of a treatment unanimous among stroke neurologists across many different countries.
Happy to engage in respectful debate on this topic
https://www.thennt.com/nnt/thrombolytics-acute-ischemic-stroke/
The burden of proof lies with those skeptical of a treatment unanimous among stroke neurologists across many different countries.
Happy to engage in respectful debate on this topic
https://www.thennt.com/nnt/thrombolytics-acute-ischemic-stroke/
