Early Management of Acute Ischemic Stroke

Early Management of Acute Ischemic Stroke

In 2013, the American Heart Association (AHA) and American Stroke Association (ASA) updated guidelines on the early management of acute ischemic stroke, representing the first update to these recommendations since 2007. Several substantial changes were incorporated into the new guidelines. The new document incorporates an AHA/ASA science advisory from 2009 that recommends the use of tissue plasminogen activator in appropriate patients who present to hospitals within 3.0 to 4.5 hours of symptom onset. It’s also recommended that door-to-needle times be less than 60 minutes for patients who are eligible for thrombolysis. The FDA approvals of the Trevo Retriever (Concentric Medical) system and Solitaire Flow Restoration (Covidien) device were significant new advances that were addressed in the guideline update. These devices are alternatives to coil retrievers and offer clinicians a new mechanical approach for restoring blood flow to occluded arteries. The updated AHA/ASA guidelines recommend that the Trevo Retriever system and Solitaire Flow Restoration device be the preferential choice when mechanical thrombectomy is pursued. Since 2007, several studies have focused on the use of decompressive surgery for malignant cerebral edema. These new data led to the recommendation that this approach be considered for acute ischemic stroke patients with large infarcts because of its potential life-saving capabilities and because it can restore a reasonable quality of life in appropriately selected patients. Implications for Emergency Medicine & Stroke Emergency physicians and nurses should be intimately integrated into the care of stroke patients. The AHA/ASA guideline recognizes that the saying “time is brain” is more critical than ever before. Timely, definitive care must be delivered in the ED. Emergency physicians need to be...

Revascularizing Occluded Arteries: Assessing the Influence of Guidelines

The Occluded Artery Trial (OAT) was a large, randomized controlled study funded by the National Heart, Lung, and Blood Institute that tested routine percutaneous recanalization of persistently totally occluded infarct-related arteries identified a minimum of 24 hours after myocardial infarction (MI) in stable patients who did not have triple vessel disease or severe inducible ischemia. In 2006, results from OAT were released, showing that there appears to be no benefit to routinely using PCI for persistently totally occluded infarct-related arteries in this patient population. Routine PCI for these arteries did not reduce mortality, reinfarction, or class IV heart failure. These results subsequently led to updates of guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) on unstable angina/non-STEMI, STEMI, and PCI in 2007. The revised guidelines recommended that PCI not be performed in this context. Prior to OAT data being released, clinicians tended to favor using PCI for persistent infarct-related artery occlusions largely because of experimental and observational data. “OAT results demonstrated that use of PCI did not lead to a reduction in clinical events,” explains Judith S. Hochman, MD. “The beneficial effect on angina and quality of life was small and not durable. OAT also suggested that PCI was more costly than optimal medical therapy alone. As a result, these findings should have discouraged routine PCI in this setting.” Assessing the Impact of the OAT Study In the October 10, 2011 Archives of Internal Medicine, Dr. Hochman and colleagues had a study published in which they examined whether PCI use for treating occluded infarct-related arteries after an MI decreased following the publication of OAT...