Use of tPA for the Management of Acute Ischemic Stroke in the ED: A...

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ACEP Clinical Policy
Use of Intravenous
Tissue Plasminogen
Activator for the
Management of Acute
Ischemic Stroke in the
Em...

This clinical policy from the ACEP
is the revision of a clinical policy
approved in 2012 addressing
critical questions in ...

Is IV tPA safe and effective
for patients with acute
ischemic stroke if given
within 3 hours of
symptom onset?

Is IV tPA safe and effective
for patients with acute
ischemic stroke treated
between 3 to 4.5 hours
after symptom onset?

The 2012 IV tPA clinical policy
recommendation to “offer” tPA to patients
presenting with acute ischemic stroke
within 3 h...

Classes of Evidence to
Recommendation Levels
Level A recommendations
Generally accepted principles for patient care that
r...

This policy is not intended to be a
complete manual on the evaluation
and management of patients with
acute ischemic strok...

This clinical policy is not intended to
represent a legal standard of care for
emergency physicians.
Recommendations offer...

Scope of Application
This guideline is intended for physicians
working in EDs
Inclusion Criteria
This guideline is intende...

Critical
Questions

Is IV tPA safe and effective
for patients with acute
ischemic stroke if given
within 3 hours of
symptom onset?

Level B recommendations
With a goal to improve functional
outcomes, IV tPA should be offered
and may be given to selected
...

Level C recommendations
When feasible, shared decision
making between the patient
(and/or his or her surrogate)
and a memb...

NINDS Criteria NEJM. 1995;333:1581-1587.
Inclusion:
• Acute ischemic stroke with
clearly defined time of onset
(who could ...

• Part 1: N=291 (144 tPA); part 2: N=333 (168
(tPA).
• No significant difference between tPA (47%)
and placebo (30%) group...

Is IV tPA safe and effective
for patients with acute
ischemic stroke treated
between 3 to 4.5 hours
after symptom onset?

Level B recommendations
Despite the known risk of sICH and
the variability in the degree of
benefit in functional outcomes...

Level C recommendations
When feasible, shared decision
making between the patient
(and/or his or her surrogate) and a
memb...

ECASS III Criteria NEJM. 2008;359:1317-1329.
Inclusion:
• Acute ischemic stroke with a
clearly defined time of onset
(who ...

Potential Benefits
and Harms of
Implementing the
Recommendations

Is intravenous tissue
plasminogen activator
safe and effective for
patients with acute
ischemic stroke if given
within 3 h...

Potential Benefit of Implementing
the Recommendations
Administration of IV tPA within 3
hours of stroke symptom onset
incr...

Potential Harm of Implementing
the Recommendations
Administration of IV tPA within 3
hours of stroke symptom onset
increas...

Is IV tPA safe and effective
for patients with acute
ischemic stroke treated
between 3 to 4.5 hours
after symptom onset?

Potential Benefit of Implementing
the Recommendations
Administration of IV tPA for patients
with ischemic stroke within 3 ...

Potential Harm of Implementing
the Recommendations
Administration of IV tPA for patients
with ischemic stroke within 3 to
...

Question

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