thrombolytics not effective in treatment of strokes?

[zzyzx]

I don't know how many of you have come across the Smart EM podcast yet, but I encourage you all to check it out.

http://smartem.org/

The latest one is a 2 - 3 hour analysis by Dr Newman and Dr Shreves of all past studies concerning the effectiveness of thrombolytics in stroke. They basically come to the conclusion that there is no good evidence to show their effectiveness, and that rather than continue their use, there should be a large government-sponsored (rather than pharm industry sponsored) trial to study them.

 

[bstone]

I've been listening to a lot of their podcasts. Very informative! Too bad we can't get ConEd for it.

 

[DrParasite]

While I admit I haven't listen to the podcast yet, do they give a more effective option to treat stroke victims?

 

[zzyzx]

You really ought to listen to the podcast--it's very interesting--but no, there really isn't any other treatment for stroke, so they have nothing to advocate.

I think you may be touching on an important point though. It's our inclination to want to help stroke victims, and since we have nothing else that we can do, this may explain why thrombolytics are being used even though the evidence for the efficacy is pretty shaky.

I recently heard someone make the point that whereas with most technology like computers and smart phones, the technology keeps getting a little cheaper and a lot better, with healthcare our treatments are only getting a little better but a whole lot more expensive. The $$$$$ spent on thrombolytics for stroke victims is a good example of that. It is interesting to me that there is so much stupid debate about Obamacare, but so little serious talk about the biggest problem with our healthcare system--how to control ever-rising costs.

 

[Veneficus]

The $$$$$ spent on thrombolytics for stroke victims is a good example of that. It is interesting to me that there is so much stupid debate about Obamacare, but so little serious talk about the biggest problem with our healthcare system--how to control ever-rising costs.

I do not partake of EMpodcast.

However, in my opinion, the rising cost of US medicine is a product of its own doing.

US medicine has elevated the threat of getting sued to divine belief. They believe the more technology and more and more diagnostics and procedures prevents them from getting sued.

They do not see there is not as much correlation to it as they attribute.

It is literally like saying "if I perform the proper ritual properly, the gods will be appeased and not smite me."

Then if somebody does get smitten, they double down because that provider made the gods angry.

 

[zzyzx]

Veneficus, do you really think that the threat of getting sued is responsible for the rising cost of healthcare? People who have studied this issue say that certainly tort reform would save billions, but those savings wouldn't make a dent in the rising costs of healthcare. Anyhow, I don't see how the use of thrombolytics for stroke treatment has anything to do with defensive medicine.

 

[exodus]

I've seen them work though...

 

[Dwindlin]

I do not partake of EMpodcast.

However, in my opinion, the rising cost of US medicine is a product of its own doing.

US medicine has elevated the threat of getting sued to divine belief. They believe the more technology and more and more diagnostics and procedures prevents them from getting sued.

They do not see there is not as much correlation to it as they attribute.

It is literally like saying "if I perform the proper ritual properly, the gods will be appeased and not smite me."

Then if somebody does get smitten, they double down because that provider made the gods angry.

This is one of your soap boxes that bothers me. The threat of litigation is real in this country, I am sorry you believe otherwise. And most physicians do not believe more diagnostics will prevent them from being sued, but having demonstrated you did EVERYTHING to foresee/prevent a bad outcome will help you not lose a suit if it goes to trial. There is a difference. You act as though US physicians don't learn how to "doctor" which isn't true, they learned it, most of them know it, but it gets skipped because this environment it isn't worth the risk of relying solely on an exam finding when there is an imaging test that will show it better. Most docs will freely admit that a lot of what they do is probably unnecessary. Foreign physicians who were completely trained overseas (where they apparently learn to be "real" doctors) end up testing almost identically to US trained after a short stint in the US again, because the risk it more real than you think.

 

[VFlutter]

Foreign physicians who were completely trained overseas (where they apparently learn to be "real" doctors) end up testing almost identically to US trained after a short stint in the US again, because the risk it more real than you think.

It has nothing to do with medical knowledge, it is the philosophy of applying that medical knowledge which is superior.

This hesitance to provide maximally aggressive care is not a problem with physicians it is a problem with our society and our view on medicine, and more so our expectation to sue for millions of dollars for any incident.

 

[Dwindlin]

It has nothing to do with medical knowledge, it is the philosophy of applying that medical knowledge which is superior.

This hesitance to provide maximally aggressive care is not a problem with physicians it is a problem with our society and our view on medicine, and more so our expectation to sue for millions of dollars for any incident.

That was my point (that it has little to do with the physician), though many will argue that they believe foreign physicians get more training in/are better at physical diagnosis than US trained (which isn't true).

 

[Smash]

I've seen them work though...

Or have you seen regression to the mean, or the natural progression of the disease process, or the effects of good quality stroke care, or half a dozen other confounding factors at work?

It is entirely possible that there is a small subgroup of patients in whom thrombolysis may be effective. However what that group is is not clear, and the point of IST-3 (and others) is that in the way thrombolytics are being used now, there is more risk of harm than of benefit. That's not what the abstract will say, because the authors have a vested interest in the drugs being used, but that seems to be the upshot of it.

 

[mycrofft]

Does it work? Do the science then come back to us. Premature or exploratory articles are released by outlets for readership stats, and by authors to flush out money.

Can we quickly and effectively differentiate between an occlusive versus haemorrhagic CVA? Or CVA-like affect from a neoplasm which has finally pressed on something vital? (I caution my lay and professional students, do not give ASA, ibuprophen, naproxen or other NSAIDS to people with headaches and ANY of the FAST signs).

Healthcare and "Big Pharm" are producing millionaires and billions of profit annually. Looks like there's more of an "all the market will bear" factor than "everything has to be expensive". (If it was all that expensive, they couldn't charge so little to bulk purchasers, even by overcharging others to make up for it; check the logic).

And read John Grisham's books about lawsuits and tort reform. Very informative and sometimes "prescient" (one book essentially predicted the Vioxx affair).

 

[JakeEMTP]

We've known the limitations and risks of thrombolytics (hemorrhagic conversion) for many years which is why patients are transferred to hospitals which have Interventional Neuroradiologists or Neurosurgeons who can do intra-arterial tPA or use a mechanical device to get the clot.These doctors can also intervene for the aneurysms and hemmorrhagic strokes. Suggested reading would be for the AHA/ASA guidelines which are always changing as new meds and technology becomes available. Those who do CCT or Flight may even have taken a patient straight to IR on a transfer from a hospital with limited capabilities to a major stroke/neuro center.

tPA just happens to be more readily available but with limitations just like we found with thrombolytics and cardiac patients who may also need a cath lab.

You can also ask a neurosurgeon what the risks and liabilities are but they inform the patient/family and still do their job assuming a huge responsibility but with confidence in their training and knowledge.

 

[Veneficus]

This is one of your soap boxes that bothers me. The threat of litigation is real in this country, I am sorry you believe otherwise. And most physicians do not believe more diagnostics will prevent them from being sued, but having demonstrated you did EVERYTHING to foresee/prevent a bad outcome will help you not lose a suit if it goes to trial. There is a difference. You act as though US physicians don't learn how to "doctor" which isn't true, they learned it, most of them know it, but it gets skipped because this environment it isn't worth the risk of relying solely on an exam finding when there is an imaging test that will show it better. Most docs will freely admit that a lot of what they do is probably unnecessary. Foreign physicians who were completely trained overseas (where they apparently learn to be "real" doctors) end up testing almost identically to US trained after a short stint in the US again, because the risk it more real than you think.

I think it is because the foreign trained docs have to meet "the standard of care." In essence, if they don't do what everyone else does, they either get sued or professionaly sanctioned.

Yes, the risk of getting sued is real, I just think it is given way more overstated than actuall happens.

In all my years working in the US as a medic, in multiple states, including Ohio, I met one doctor who was sued 1 time, and it didn't make it to trial before it was dismissed.

Obviously the suits in Europe are much less for much less.

As for being a doctor, I think it is like anything else. You can learn how to start an IV, but if you never do it, eventually the skill fades.

I think that the real savings in healthcare will be doctors not being forced to prove they did everything possible on every patient. That is simply a long way from tort reform.

Actually it is a complicated issue, that ties into many more aspects of medicine. Things like it being less money for insurance to settle than to fight a claim.

I just don't think more and more tests and diagnostics and running down zebras is the way. If you spend hundreds of billions to save being sued a few hundred million, the system will never work. It's just math.

 

[mycrofft]

I think lawsuits, as a primary barrier to care and a cost-raising excuse/cause, needs a sticky thread all its own.

MD's etc working for a hospital or other deep pocket may never find out how many suits are flying their way, but will get called in about errors and patient satisfaction. Especially the latter.

 

[Veneficus]

I think lawsuits, as a primary barrier to care and a cost-raising excuse/cause, needs a sticky thread all its own.

MD's etc working for a hospital or other deep pocket may never find out how many suits are flying their way, but will get called in about errors and patient satisfaction. Especially the latter.

Wise words that were once conveyed to me.

"Take the time and effort to make every patient your friend. You would never sue your friend... You would gladly sue your enemy."

 

[mycrofft]

Roger that, and it probably makes you listen to the patient better also!

So thrombolytics need more scientific bases for control and utilization. Seems to me the "guvmint" could demand the data to justify payment or subsidy (science by case management) then do a study.

 

[bstone]

Their podcasts are incredibly informative. They clearly delve very deeply into the data. Dr Newman says he would not use thrombolytics for stroke as the evidence doesn't show that it helps and that it might kill the patient. Dr Shreeves pointed out that the internaitonal stroke study showed that it did help in 6% of the cases. Dr Neuman further stated he wished there were be heavily randomized studies to further flesh out thrombolytics. I think he's a bigger fan of catheterization or supportive treatment for non-severe strokes.

 

[KellyBracket]

We know what saves lives in CVA - Excellent specialized nursing care. Stuff like aspiration precautions, skin care, and not putting in a Foley improve outcomes more than a drug or device.

The use of MERCI and other thrombectomy devices hasn't actually been shown to improve outcomes, as far as I know. It's very satisfying to suck out a clot, but it might not help the patient move their arm.

It's funny - for all the hype about "code stroke," and clot-buster drugs in the media, when patients and families actually hear the risks and benefits of tPA, they tend to make a face like :unsure:

For example, I use pretty conventional explanations of risk and benefit. From the NINDS trial, the number-needed-to-treat is about 8, while he risk of ICH goes from 0.6 % to 6%. Suddenly, it doesn't like a miracle drug, but more like a desperate gamble.

If I use a graphic interpretation of the data, like you can find from AAEM here (PDF download), it makes the slim benefit and real danger all the more stark.

 

[JakeEMTP]

We know what saves lives in CVA - Excellent specialized nursing care. Stuff like aspiration precautions, skin care, and not putting in a Foley improve outcomes more than a drug or device.

Those are part of basic patient care for all patients and not just CVA. Interventiions to help a patient maintain/regain a gag and swallow is also just as vital.

The use of MERCI and other thrombectomy devices hasn't actually been shown to improve outcomes, as far as I know. It's very satisfying to suck out a clot, but it might not help the patient move their arm.


.

The article you posted states differently.

Since you are a physician, have you contacted the doctors on that link to see what their results are now since that article was a few years ago and it is probably based on research done a few years before publication?

The other article you posted for tPA contains data from almost 20 years ago. In medicine that is almost a lifetime ago. Do you have anything within the past couple of years?