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Effective Stroke Drug Underused

Only 2 percent of patients are getting the lifesaving therapy, study finds

MONDAY, May 9, 2005 (HealthDayNews) -- A clot-dissolving drug called tissue plasminogen activator (tPA) is as effective in real-life settings as it has been in clinical trials, Canadian researchers report.

Yet, despite tPA's ability to significantly improve outcomes among stroke victims, it is being given to only about 2 percent of such patients, according to the report in the May 10 issue of the Canadian Medical Association Journal.

"We need to get more aggressive about treating more people faster," said study author Dr. Michael D. Hill, an associate professor of neurology at the University of Calgary. "tPA therapy has been a little controversial, and in some cases doctors have been reluctant to use it."

The drug is approved for use in certain patients having a heart attack or stroke. It works by dissolving blood clots, which are the cause of most heart attacks and strokes. It works best when given within three hours of the onset of a stroke or heart attack.

In the Canadian study, Hill and his colleagues collected data on 1,135 stroke patients admitted to 60 Canadian hospitals between 1999 and 2001, all of whom were treated with tPA. The outcome was excellent for 37 percent of these patients. However, 75 percent of the patients died in the hospital.

For Hill, the important finding is that tPA works in real-life medicine. "We can replicate what's been done in randomized trials," he said. "We can do it safely at academic hospitals, small hospitals, rural places and big cities."

This finding should help ease concerns among doctors that tPA therapy is complex, and can only be done in academic hospitals, Hill said. "Reality is that even if you're in a small hospital, with a CAT scan and a little bit of training, you can do it."

In Canada, tPA is given to only about 2.5 percent of stroke patients. "It's good therapy, and we need to give it to more people," Hill said. "Imagine if we could treat even 10 percent of the strokes. We would substantially reduce the burden on society of caring for people who are sick in the long term."

Another expert finds the Canadian study valid. "This study is right in line with all the other studies that have come out over the last several years," said Dr. Justin A. Zivin, a professor of neurosciences from the University of California, San Diego, and a pioneer in the use of tPA to treat stroke.

Zivin agrees with Hill that the drug is an important treatment, adding, "tPA should be used a lot more than it currently is."

Zivin pointed to two reasons why tPA is underused. First, it has been controversial because when it was first used there were problems -- such as increased risk of bleeding -- that were later fixed, but many doctors only remember the problems, he said.

"The second issue is that it costs a lot of money," Zivin said, although nowhere near as much as caring for a stroke victim. "In the U.S., insurance reimburses hospitals about $5,700 for taking care of a stroke patient. And the physician who uses tPA gets $500. It costs way more than that to take care of those patients."

"It [tPA] is a money saver," he added. "And very few things in medicine are cost-effective, but tPA is one of them."

In the best U.S. hospitals, with grants to use tPA, about 15 percent to 20 percent of the patients receive the drug, and in other hospitals only about 2 percent to 3 percent get the drug, Zivin said. "It should be 40 percent," he added. "Patients should get into the hospital as quickly as they can after the onset of their stroke and demand appropriate care."

Although stroke experts sing the praises of tPA, not all doctors are convinced.

In a new report, a survey of 2,600 emergency doctors in the United States found that 40 percent were unlikely to give tPA, even under ideal conditions, because of the risk of bleeding in the brain.

"It appears that individual anecdotal experience is influencing decision-making, when it should be the medical literature that leads the way," study author Dr. Devin Brown, a stroke neurologist at the University of Michigan, said in a prepared statement.

The study appears in the May online issue of the Annals of Emergency Medicine.

"This survey shows that there's still major resistance to tPA use in the emergency medicine community, but we shouldn't blame emergency department physicians or ask them to handle this decision alone," Brown said. "Only through team decision-making will we be able to change current practice and improve acute stroke care delivery."

More information

The American Heart Association can tell you more about stroke and tPA.

SOURCES: Michael D. Hill, M.D., associate professor, neurology, University of Calgary, Canada; Justin A. Zivin, M.D., Ph.D., professor, neurosciences, University of California, San Diego; May 10, 2005, Canadian Medical Association Journal; May 2005 Annals of Emergency Medicine online
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