TPA and Stroke 2

Geez, the NY Times (obscure liberal paper in the Northeast) has interviewed several neurologists (and exactly one Emergency Medicine Physician) and has written a four-page article on stroke. They got little right.

It’s a tour-de-force in obfuscation of fact, presentation of tragedy as preventable, and the presentation of TPA as an ignored wonder-drug, MRI should be the standard of care for new strokes, and frankly there’s no redeeming value within. Nevertheless, I shall persevere, and even if it makes nobody other than me happy, I shall fisk to my hearts’ content. (Many thanks to Notes from Dr. RW for bringing this to my attention, and for taking the hit for the rest of us and reading the NY Times, you poor wretch).

I was going to address this in the article as I got to it, but it’s too good / on point to bury below the fold. Here’s all you need to know about tPA for CVA (from AAEM), in a nice graphical form:

Lost Chances for Survival, Before and After Stroke

By GINA KOLATA

Dr. Diana Fite, a 53-year-old emergency medicine specialist in Houston, knew her blood pressure readings had been dangerously high for five years. But she convinced herself that those measurements, about 200 over 120, did not reflect her actual blood pressure. Anyway, she was too young to take medication. She would worry about her blood pressure when she got older.

Then, at 9:30 the morning of June 7, Dr. Fite was driving, steering with her right hand, holding her cellphone in her left, when, for a split second, the right side of her body felt weak. “I said: ‘This is silly, it’s my imagination. I’ve been working too hard.’ ”
Suddenly, her car began to swerve.

“I realized I had no strength whatsoever in my right hand that was holding the wheel,” Dr. Fite said. “And my right foot was dead. I could not get it off the gas pedal.” …

Dr. Fite is one of an estimated 700,000 Americans who had a stroke last year, but one of the very few who ended up at a hospital with the equipment and expertise to accurately diagnose and treat it.

Dr. Fite has been active in the practice and politics of Emergency Medicine for a good while, and I was unaware of her stroke. I hope she’s recovering well.

Stroke is the third-leading cause of death in this country, behind heart disease and cancer, killing 150,000 Americans a year, leaving many more permanently disabled, and costing the nation $62.7 billion in direct and indirect costs, according to the American Stroke Association.

But from diagnosis to treatment to rehabilitation to preventing it altogether, a stroke is a litany of missed opportunities.

Many patients with stroke symptoms are examined by emergency room doctors who are uncomfortable deciding whether the patient is really having a stroke — a blockage or rupture of a blood vessel in the brain that injures or kills brain cells — or is suffering from another condition. Doctors are therefore reluctant to give the only drug shown to make a real difference, tPA, or tissue plasminogen activator.

This is a truckload of hooey. Any Emergency Physician worth the title does this for a living, and while it’s challenging to sort wheat from chaff, it’s why Emergency Medicine exists as a specialty. Yes, there is a tremendous differential diagnosis, but that goes with the territory. And reluctance to administer tPA for stroke is more than reluctance, there are solid reasons to be very very careful with the decision.

[Read more...]

WSJ on Stroke: TPA is a wonder drug for stroke!

Summary: Neurologists are excellent with acute stroke, EM docs are stupid, and anyone against TPA is backward.

I have read this twice, and am of the opinion the reporter was assigned the topic “stroke” to write about, then talked to a neurologist who was a big fan of TPA for stroke. It is filled with “they’re stupid if they don’t embrace…”, TPA for stroke (which I’ve written about before), and then it just keeps getting worse:

Stroke victims are often taken to wrong hospital

Monday, May 09, 2005
By Thomas M. Burton, The Wall Street Journal

Christina Mei suffered a stroke just before noon on Sept. 2, 2001.
Within eight minutes, an ambulance arrived. Her medical fate may have
been sealed by where the ambulance took her.


Ms. Mei’s stroke, caused by a clot blocking blood flow to her brain,
occurred while she was driving with her family south of San Francisco.
Her car swerved, but she was able to pull over before slumping at the
wheel. Paramedics saw the classic signs of a stroke: The 45-year-old
driver couldn’t speak or move the right side of her body.

Had Ms. Mei’s stroke occurred a few miles to the south, she probably
would have been taken to Stanford University Medical Center, one of the
world’s top stroke hospitals. There, a neurologist almost certainly
would have seen her quickly and administered an intravenous drug to
dissolve the clot. Stanford was 17 miles away, across a county line.


But paramedics, following county ambulance rules that stress proximity,
took her 13 miles north, to Kaiser Permanente’s South San Francisco
Medical Center. There, despite her sudden inability to talk or walk and
her facial droop, an emergency-room doctor concluded she was suffering
from depression and stress. It was six hours before a neurologist saw
her, and she never got the intravenous clot-dissolving drug.

Woah, pardner. There has to be more to the story than this; if not, there’s an idiot for an ER doc. As the vast majority aren’t idiots, the above makes no sense.

However, the ‘..almost certainly would have..administered an IV drug to dissolve the clot…’ is only about 1/10th of the story. However, just reading this article, I’d be ticked off if I didn’t get TPA for a stroke.


Stroke is the nation’s No. 1 cause of disability and No. 3 cause of
death, killing 164,000 people a year. But far too many stroke victims,
like Ms. Mei, get inadequate care thanks to deficient medical training
and outdated ambulance rules that don’t send patients to the best
stroke hospitals.

Uh, deficient medical training? Based on what fact is this assertion made? There exists a lot of controversy about the use of TPA in stroke, and that isn’t because of ‘deficient training’, it’s because very smart people have looked at the literature, evaluated the risks, combined those with their clinical experience and then came to differing conclusions.


Over the past decade, American medicine has learned how to save stroke
patients’ lives and keep them out of nursing homes. New techniques
offer a better chance of complete recovery by dissolving blood clots
and treating even more lethal strokes caused by burst blood vessels in
the brain. But few patients receive this kind of treatment because most
hospitals lack specialized staff and knowledge, stroke experts say.
State and county rules generally require paramedics to take stroke
patients to the nearest emergency room, regardless of that hospital’s
level of expertise with stroke.

There’s a paragraph about stroke care needing to be like Trauma care, deleted.


Eighty percent or more of the 700,000 strokes that Americans suffer
annually are “ischemic,” meaning they are caused by blockage of an
artery feeding the brain, usually a blood clot. Most of the rest are
“hemorrhagic” strokes, resulting from burst blood vessels in or near
the brain. Although they have different causes, both result in brain
tissue dying by the minute.


Several factors have combined to prevent improvement in stroke care. In
some areas, hospitals have resisted movement toward a system of
specialized stroke centers because nondesignated institutions could
lose business, according to neurologists who favor the changes. In
addition, stroke treatment has lacked an organized lobby to galvanize
popular and political interest in the ailment.

Nobody I know wants to ‘prevent improvement in stroke care’. And the idea that an organized lobby is needed to push this agenda is ludicrous.

A big reason for the backwardness of much stroke treatment is that many
doctors know little about it. Even emergency physicians and internists
likely to see stroke victims tend to receive scant neurology training
in their internships and residencies, according to stroke specialists.


“Surprisingly, you could go through your entire internal-medicine
rotation without training in neurology, and in emergency medicine it
hasn’t been emphasized,” says James C. Grotta, director of the stroke
program at the University of Texas Health Science Center at Houston.

This is just twaddle. EM residency programs cover neurology of emergencies very well, thank you. It’s part of the EM curricula, and it’s part of the tests and training. IMHO, EM docs see way more acute strokes than do neurologists.


Many hospitals don’t have a neurologist ready to deal with emergencies.
As a result, strokes aren’t treated urgently there, even though short
delays increase chances of severe disability or death. Even if doctors
do react quickly, recent research has shown that many aren’t sure what
treatment to provide.

True, most hospitals don’t have neurologists available to treat emergencies (and those that do have trouble getting them to come in). That ‘lack of neurologists’ has nothing to do with a delay in stroke care. Delays are delays, and every hospital has a way to prioritize tests and treatments. Lack of neurologists doesn’t equal lack of priority.


For example, a survey published in 2000 in the journal Stroke showed
that 66 percent of hospitals in North Carolina lacked any protocol for
treating stroke. About 82 percent couldn’t rapidly identify patients
with acute stroke.

What? Couldn’t rapidly identify patients with an acute stroke? That’s just nonsensical. Any EM trained doc, or an ER nurse with 6 months’ experience can identify people with ‘possible stroke symptoms’ and start the eval right then. As for the lack of protocol, well, there’s a whole argument about checklist medicine, and whether protocols are helpful or harmful.

As with other life-threatening conditions, stroke patients are better
off going where doctors have had a lot of practice addressing their
ailment. A seven-year analysis of surgery in New York state in the
1990s showed that patients with ruptured blood vessels in the brain
were more than twice as likely to die — 16 percent versus 7 percent –
in hospitals doing few such operations, compared with those doing them
regularly. A national study published last year in the Journal of
Neurosurgery showed a similar disparity.

Okay, here we start mixing our apples and oranges; that was (probably) about aneurysm surgeries, very different for the vast majority of ischemic CVA’s.


Another major shortcoming of most stroke treatment
, according to many
neurologists, is the failure to use the genetically engineered
clot-dissolving drug known as tPA.
Short for tissue plasminogen
activator, tPA, which is made by Genentech Inc., has been shown to be a
powerful treatment that can lessen disability for many patients. A
study published in 2004 in The Lancet, a prominent medical journal,
showed that the chances of returning to normal are about three times
greater among patients getting tPA in the first 90 minutes after
suffering a stroke, even after accounting for tPA’s potential side
effect of cerebral bleeding that can cause death
. But several recent
medical-journal articles have found that nationally, only 2 percent to
3 percent of strokes caused by clots are treated with tPA, which has no
competitor on the market.


Some authors of studies supporting the use of tPA have had consultant
or other financial relationships with Genentech. Skeptics of the drug
point to these ties and stress tPA’s side-effect danger. But among
stroke neurologists, there is a strong consensus that the drug is
effective.

If they were pushing, say, Bush administration talking points and got caught taking money for it, they’d be pariahs to the press. Double standard for those pushing medical interventions, I suppose.

But, let’s not gloss over the side effect: taking an injured brain and making it substantially worse, in 6-9% of cases. That’s not an intervention to rally around, it’s one to be feared, and to be engaged only when the benefits very clearly outweigh the risks.

The article is very much longer, and reads like the neurologist dream agenda. The slant of the article is so pro-neurologist and so anti-EM doc, though, and gives short shrift to the other side of th TPA controversy, it’s impossible to take seriously.