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A Look at Current Stroke Treatment
What's
Changed in 2000?
“EMS systems should implement a prehospital
stroke protocol to evaluate and rapidly identify patients
who may benefit from fibrinolytic therapy, similar to the
protocol for chest pain patients” (Class IIb).
“Patients who may be candidates for fibrinolytic
therapy should be transported to hospitals identified as capable
of providing acute stroke care, including 24-hours availability
of CT scan and interpretation.” (Class IIb).
“Stroke presenting with 3 hours should be triaged
on an emergent basis with urgency similar to acute ST-elevation
myocardial infarction.” Intravenous fibrinolysis
for acute ischemic stroke
- Class I
IV - t-PA within 3 hours of onset
- Class Indeterminate
IV - t-PA between 3 and 6 hours of onset
Intra-arterial fibrinolysis
- Class IIb
IA prourokinase within 3 to 6 hours after symptom onset
What Has
Not Changed
Impact of Stroke
- 3rd leading cause of death in the U.S.
- Leading cause of adult disability
- Over 700,000 new stroke cases per year in U.S. with 150,000
stroke deaths per year
- 85% are ischemic
- Less than 25% of eligible thrombolytic candidates receiving
therapy
Acute Stroke
Where are we today?
- Public poorly informed
- Response time too slow
- Presentation too late
- Hospitals ill prepared
- Fatalistic
Models
for the "Golden Hour"
Trauma
- Golden hour for intervention
- Centralized trauma center system, certified by the ACS
Acute myocardial infarction
- Similar door-drug/groin benchmarks for reperfusion
- Decentralized system
Trauma - example
Stab wound to the abdomen
- Very rapid EMS activation and transport
- Not exactly a difficult diagnosis
- Lots of communication
- Big teams
- Detailed protocols
- “The Golden Hour”
- What is the mortality and morbidity? - Low
Acute
Myocardial Infarction - example
The paradigm has shifted
- Chest pain - patients know to call 911
- Rapid access to EMS
- Pre-hospital identification and call
- Pre-hospital ECG
- Team, protocols, drugs in the ED
- “Door to Drug” in 30 Minutes
- What is the mortality and morbidity? - Low.
Forces of Change
- Public expectations
- Aware of “Draino for the Braino”
- Nihilistic attitude of stroke changing
- Medical - legal pressures
- Managed care cost concerns
- New treatments of stroke on horizon
- Change in treating physicians' perceptions of “risk”
Organized Stroke
Care Saves Lives
- 21% reduction in early mortality
- 18% reduction in 12 month mortality
- Decreased length of hospital stay
- Decreased need for institutional care
Cost Effectiveness for
rt-PA in Acute Ischemic Stroke
With rt-PA, considering 1,000 eligible patients:
- Hospitalization costs = $1.7 million more
- Rehabilitation costs = $1.4 million less
- Nursing home costs = $4.8 million less
- 564 quality-adjusted life-years saved
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Stroke Education
