Stroke patients who were older and had disturbances of their consciousness had a greater risk of death in the hospital following thrombolytic (clot-dissolving) therapy, according to an article in the October 20 JAMA.

Intravenous clot-dissolving treatment with tissue plasminogen activator (tPA) is currently the only approved treatment for patients with acute ischemic stroke and is recommended in the guidelines of several national and international stroke associations, according to background information in the article. Clarification of clinical factors associated with early death in patients treated with tPA could help identify subgroups of patients with increased risks and thereby allow clinicians to give special attention to these patients after tPA treatment.

Peter U. Heuschmann, M.D., M.P.H., of the University of Muenster, Germany, and colleagues conducted a study to identify predictors of in-hospital death in patients with ischemic stroke treated with tPA outside of clinical trials. The study was conducted at 225 community and academic hospitals throughout Germany cooperating within the German Stroke Registers Study Group. The study included 1,658 patients with acute ischemic stroke who were admitted to study hospitals between 2000 and 2002 and were treated with tPA.

The researchers found that 166 patients (10 percent) who received tPA died during hospitalization, with 67.5 percent of these deaths occurring within 7 days. Factors predicting in-hospital death after tPA use were older age (for each 10-year increment in age, a 60 percent greater risk) and altered level of consciousness (3.4 times increased risk). One or more serious complications was observed in 27.2 percent of all patients and in 83.9 percent of patients who died after tPA treatment. Risk of in-hospital death after thrombolysis decreased with increasing experience of the treating hospital in tPA administration, indicating an inverse relation.

"Clinicians should give special attention to patients with disturbances of consciousness and older age for reducing rates of in-hospital mortality after tPA treatment," the authors conclude.

(JAMA. 2004; 292: 1831-1838. Available post-embargo at www.jama.)

Editor's Note: The data analyses and the data pooling of the German Stroke Registers Study Group are funded by the German Federal Ministry of Research (BMBF) within the Competence Net Stroke.

Editorial: Treatment of Acute Stroke - Still Struggling

In an accompanying editorial, Louis R. Caplan, M.D., of Beth Israel Deaconess Medical Center, Boston, examines the studies on stroke in this week's JAMA.

"Therapeutic decisions for acute stroke must be based on all available information including experience, observational studies, and the desires of the patient, not solely on randomized controlled trials," he writes. "Trials consider large cadres of patients--physicians treat individual patients. Knowing that a given treatment helps 60 percent of patients in a stroke trial does not always translate into knowing the effectiveness of that treatment in a given patient with a given lesion and a known extent of infarction, especially when these factors were not studied in that trial."

"Stroke diagnosis has come a long way, but there is a huge gap between currently available sophisticated diagnostic capabilities and the knowledge of treatment, such that less than 5 percent of patients with ischemic stroke are now being treated with [a clot-dissolving drug]. Developing more qualified stroke centers and finding ways to get patients to those centers quickly are urgently needed, as are more experienced stroke clinicians and wider distribution of modern diagnostic technology. Although stroke treatment has witnessed some important gains, the struggle to reverse acute cerebral ischemia and preserve neurological function in acute stroke continues," Dr. Caplan concludes. (JAMA. 2004; 292: 1883-1885. Available post-embargo at www.jama.)

Contact: Peter U. Heuschmann, M.D., M.P.H.
heuschmauni-muenster.de
JAMA and Archives Journals Website

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