Dr. Sara Hevesi is an EM consultant in Rochester, MN
The second Mayo EM residency journal club of the year met on August 8th, hosted by Chief Resident Dr. Maria Kaisler. We reviewed the classic NINDS trial for using tPA in ischemic strokes, an SGEM review critically appraising the evidence behind tPA (http://thesgem.com/2020/07/sgem297-tpa-advocates-be-like-never-gonna-give-you-up/), and the EXTEND-IA trial comparing alteplase to tenecteplase before thrombectomy. Due to COVID, we again opted to have a small in-person group meet with other participants joining virtually via Zoom. Some of our brilliant pharmacy colleagues joined us for this discussion and pharmacist Dr. Elizabeth Canterbury even reviewed and presented one of the articles. We were also happy to have three of our medical students join us this month!
There are two articles that showed benefits of tPA in stroke patients; the NINDS and the ECASS-III trials. The bottom line from the NINDS article was better clinical outcomes within 90 days in patients who received tPA in comparison to placebo despite increased risk of bleeding. The clinical outcomes were assessed by the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS. The SGEM review argued that there was an imbalance in the baseline characteristics between the placebo and tPA group. The placebo group had a higher NIHSS score, higher rate of large vessel occlusion, higher smoking rate and less patients were taking daily aspirin. Therefore, the placebo group was “sicker” to start with. In addition, the benefits, if any, were seen in patients who received tPA within 0-90 minutes rather than 90-180 minutes, which leaves a narrow window for potential tPA benefits.
The ECASS-III trial reached a similar conclusion to the NINDS trial in which the treatment group had better outcomes after 90 days in contrast to the placebo group. A re-analysis was done in 2020 by BMJ Evidence-Based Medicine which showed that the placebo group had higher NIHSS and higher number of previous strokes which are both predictive of worse outcomes. To date, there is no clear evidence that tPA benefits outweigh the risks. The questionable outcomes of these trials and lack of clear evidence led to some good discussions amongst the group and thoughts about what future guidance may be.
Elizabeth created a very impressive review sheet covering the evidence behind tenecteplase versus alteplase before thrombectomy and critically appraising this. The bottom line was that tenecteplase is more fibrin-specific than alteplase and therefore leads to a theoretical benefit in that regard, is given via bolus adding to ease of administration, and seems to be at least equally effective with similar safety profile. This may be the ischemic stroke treatment of the future, so stay tuned!
This Saturday brunch journal club was complete with some delicious breakfast tacos from Taco JED and Caribou coffee. The medical students brought Dunkin Donuts as well! The next journal club will be held on September 16th. We will be meeting at Dr. Neha Rauker’s house, one of our fantastic consultants and discussing using CT as a diagnostic modality to rule out traumatic arthrotomy as covered in April’s ACEP Now.