Stroke: Patients Not Getting the Treatment They Need

Investigators have reported that, for patients already hospitalized at a major US teaching hospital who suffer an ischemic stroke, there is no guarantee of receiving recommended thrombolytic therapy, even if there are no contraindications to the treatment. This suggests that greater awareness of acute stroke management is required to improve current practice.

A review of the stroke service in State University of New York Upstate Medical Center in Syracuse has revealed that, while the majority of the in-patients who suffered a stroke and did not receive the therapy were not eligible for it, 33% of the stroke patients had no absolute contraindications for tissue plasminogen activator (tPA) therapy, but none received it.

The findings are shocking as the proportion of patients not receiving the vital therapy could be ever greater in community hospitals.

Thrombolytic therapy is the only available pharmacological revascularization strategy, and tPA is the only available thrombolytic for acute stroke. It has been available in the US for this indication since 1996 but, even now, is not as widely administered as it should be.

There could be several reasons for this. One possibility is that there appear to be substantial psychological barriers to using tPA within the physician community, reflecting an extreme degree of risk aversion driven and sustained by fear of failure on one hand, and fear of harming patients on the other.

In the setting of acute stroke, therapeutic decisions are not only taken under time pressure but also carry the risk of worsening a patient’s condition. Unsurprisingly, a number of physicians confronted with stroke patients are likely to display a high degree of risk aversion and refuse to opt for tPA, even if the patient qualifies for the treatment.

Another important consideration is that dealing with a stroke patient quickly and efficiently depends on the training and the experience of the physician. All of the educational programs directed toward non-stroke physicians and paramedics have to be refreshed regularly to have a lasting effect on the standard of care in the acute stroke setting. It may also be important to have stroke physicians working on dedicated stroke units rather than allowing the hospital to involve them into the day-to-day running of geriatric clinics or neurology wards.

Overall, the limited use of the tPA in stroke patients could be raised through improving the levels of awareness and training among physicians, with regard to the importance of both fast symptom recognition and the benefits of the therapy.