Ken Milne MD
@TheSGEM
Remember to be skeptical of anything you learn, even if you heard it on the Skepticsβ Guide to EM. (he/him)
11-07-2012 22:10:32
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Updated the table now that there are no RCTs showing efficacy of thrombolysis for acute ischemic stroke. This with the re-analysis of NINDS and ECASS-3 controlling for baseline differences.
American Heart Association Heart & Stroke
Ken Milne MD American Heart Association Heart & Stroke Dr. Brian Goldman CAEP Anand Swaminathan MD MPH π³οΈβππΊπ¦ Jeremy Faust MD MS (ER physician) Centre for Clinical Research in Emergency Medicine BMJ Evidence-Based Medicine ACEP Members Eddy Lang Salim R. Rezaie, MD Saint Emlyn's This seems a little misleading...many of these used streptokinase or alternate dosing of alteplase. Several have positive functional outcomes < 3 hours. A reanalysis does not negate the original RCT (btw from β08); 12 years of real world evidence showing efficacy within 4.5hrs
Eric American Heart Association Heart & Stroke Dr. Brian Goldman CAEP Anand Swaminathan MD MPH π³οΈβππΊπ¦ Jeremy Faust MD MS (ER physician) Centre for Clinical Research in Emergency Medicine BMJ Evidence-Based Medicine ACEP Members Eddy Lang Salim R. Rezaie, MD Saint Emlyn's How is it misleading to say thrombolysis. Did not say alteplase. Previous Cochrane SRMS say thrombolytics have a class effect. Reasonable to think higher does tPa would have more efficacy - nope. Which RCT showed significant efficacy for primary outcome?
Eric American Heart Association Heart & Stroke Dr. Brian Goldman CAEP Anand Swaminathan MD MPH π³οΈβππΊπ¦ Jeremy Faust MD MS (ER physician) Centre for Clinical Research in Emergency Medicine BMJ Evidence-Based Medicine ACEP Members Eddy Lang Salim R. Rezaie, MD Saint Emlyn's Never claimed re-analysis negated original trial.
My position is it raised my skepticism and encourage that policy makers and clinicians should re-consider this treatment modality.
Eric American Heart Association Heart & Stroke Dr. Brian Goldman CAEP Anand Swaminathan MD MPH π³οΈβππΊπ¦ Jeremy Faust MD MS (ER physician) Centre for Clinical Research in Emergency Medicine BMJ Evidence-Based Medicine ACEP Members Eddy Lang Salim R. Rezaie, MD Saint Emlyn's Can you acknowledge that 12 years of clinical experience is at high risk of bias?
Do you agree that stroke patients deserve the best care, based on the best evidence?
Ken Milne MD American Heart Association Heart & Stroke Dr. Brian Goldman CAEP Anand Swaminathan MD MPH π³οΈβππΊπ¦ Jeremy Faust MD MS (ER physician) Centre for Clinical Research in Emergency Medicine BMJ Evidence-Based Medicine ACEP Members Eddy Lang Salim R. Rezaie, MD Saint Emlyn's Sry was referring to chart. Agree to both those questions. How old is that SRMS? Iβd argue fibrinolytics donβt have a class effect, fibrin specificity is quite different.
Eric Ken Milne MD American Heart Association Heart & Stroke Dr. Brian Goldman CAEP Anand Swaminathan MD MPH π³οΈβππΊπ¦ Jeremy Faust MD MS (ER physician) Centre for Clinical Research in Emergency Medicine BMJ Evidence-Based Medicine ACEP Members Eddy Lang Salim R. Rezaie, MD Saint Emlyn's Agree this is tricky. From basic science (as you show) a difference is plausible & should be explored. The (limited) trial data doesn't seem to support it in patients. (From cochranelibrary.com/cdsr/doi/10.10β¦). I am unconvinced of benefit currently, would welcome good non-industry trials.
