A brain scan followed by quick drug treatment in the right patients can stop a stroke in its tracks.
A brain scan followed by quick drug treatment in the right patients can stop a stroke in its tracks. iStockphoto.com
It's been a long and often controversial road, but U.S. doctors are finally embracing a drug that can halt strokes and prevent disabling brain damage.
An analysis of more than 1 million stroke patients shows that use of the 17-year-old drug, called alteplase (brand-name Activase), nearly doubled between 2003 and 2011.
The study indicates that use of the therapy jumped from 43 percent to 77 percent over the past decade among those lucky patients who got to a hospital within two hours of their first stroke symptoms and had no disqualifying factors.
"That's very encouraging," study author Dr. Deepak Bhatt tells Shots. "That's a very large increase. But 23 percent of eligible patients still aren't getting it."
Alteplase treatment doesn't guarantee a good outcome. But studies have shown that 30 percent of stroke patients who get it have less long-term disability, and some patients have remarkable recoveries. Twelve percent recover with little or no disability.
The results show that many U.S. hospitals are recognizing the need for speed in treating a stroke in progress with clotbusting therapy. They also suggest that doctors are getting more comfortable with using the drug properly. It can cause dangerous brain hemorrhages if used in the wrong patients.
The analysis was published by a journal called Circulation Cardiovascular Quality Outcomes.
Encouraged as he is, Bhatt, a stroke specialist at Brigham and Women's Hospital in Boston, acknowledges that the data "might represent a best-case scenario."
That's because the 1,700 hospitals that furnished the data are the ones most focused on stroke care. They're voluntary participants in an American Heart Association/American Stroke Association program called Get With the Guidelines that pushes the use of alteplase.
And the study does not reflect the most fundamental problem in stroke care: Most of the nearly 800,000 Americans who will have a stroke this year won't get to a hospital in the required time frame — up to 4 1/2 hours after symptoms begin, under current guidelines.
Of those who do, only a fraction will be eligible for alteplase therapy — about 1 in 3 of those who arrive within two hours of symptom onset.
To be eligible, patients have to suffer the type of stroke caused by a blood clot in a cerebral artery, not one caused by bleeding within the brain. And they can't be taking blood thinners or have conditions that make them likely to hemorrhage.
Taking into account all the stroke patients who arrive at the hospital within three hours of symptoms, whatever contraindications they had, the new study finds that only 7 percent got clotbusting treatment in 2011. But that's better than in 2003, when only 4 percent did.
Bhatt, who chairs the Get With the Guidelines steering committee, says the new data show many hospitals are shortening the time to do the CT scans necessary to diagnose strokes correctly.
They're also doing better in getting clotbusting therapy to nonwhite patients, who have higher stroke rates. And they're getting more comfortable using the treatment in patients over 85.
All of this suggests an evolution in attitudes about clotbusting therapy since the early 2000s, when many skeptics doubted its benefits and argued that it posed too great a risk of brain hemorrhages. Critics also charged that advocates of the therapy, including the American Heart Association, were biased by drug industry funding.
"We believe the needle has been moved," Bhatt says. "That's something to be happy about. But there's a lot of room for improvement compared to heart attack therapy. The vast majority of patients coming in with heart attack are getting timely treatment, and that's associated with a pretty dramatic reduction in heart attack mortality and bad outcomes.
"Our hope with stroke," he says, "is to do what was done with heart attack patients."