Wider window for alteplase use does not delay treatment
Extending the window for alteplase use in ischaemic stroke from three hours to four and a half hours has not affected admission-to-treatment times (Lancet Neurology 2010;9:866).
In 2008, the “European co-operative acute stroke study III” provided evidence to extend the window for alteplase use in ischaemic stroke from 3h to 4.5h (New England Journal of Medicine 2008;359:1317).
According to the authors of the Lancet Neurology study, there were concerns that the wider window could mean that, when patients presented to emergency departments with stroke, there might be a delay in starting alteplase treatment.
To investigate this, they analysed data from 23,942 patients in the “Safe implementation of treatment in stroke — international stroke thrombolysis registry”. They found that the total number of patients treated with alteplase increased (in both the 0–3h and 3–4.5h windows), but admission-to-treatment times did not increase overall.
Helen Williams, who is a consultant pharmacist for cardiovascular disease in South London, told Clinical Pharmacist: “Until recently thrombolysis for acute ischaemic stroke has been limited by a very narrow 3h time window for administration from the onset of stroke symptoms, which is hampered further by the failure of patients to present for treatment early.”
She said that much has been done to improve public awareness of stroke symptoms and encourage early presentation for treatment. Nonetheless, only about 10% of patients receive thrombolysis within the 3h time window.
“The extended administration time to 4.5h has now been shown to be effective and safe in randomised controlled trials and observational studies. This increases the proportion of patients that can benefit from thrombolysis for acute ischaemic stroke and should impact on stroke outcomes over time.”
She added: “Although alteplase is not licensed for use in acute stroke beyond 3h, the extended time window has been endorsed by the European Stroke Association and the American Heart Association. National Institute for Health and Clinical Excellence guidance for stroke management issued in 2008 has yet to be updated.”
Citation: Clinical Pharmacist URI: 11023000
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