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[tvoivozhd <tvoivozd AT infionline.net>]

I was part of the first group to receive TPA after a heart attack 
instead of streptokinase. Only reason I escaped with no heart damage. 
Idiot doctors know its value in strokes, but only use it in 3% of cases.

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Saturday, February 5

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A Decade After a Drug Revolutionizes Stroke Care, Only 3 Percent Get It

*By Marilynn Marchione* The Associated Press
Published: Feb 5, 2005

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NEW ORLEANS (AP) - Ten years ago, a crucial study proved that a drug 
could limit the damage from one of nature's biggest train wrecks: a 
blood clot stuck inside the head.

The drug, TPA, was so powerful at dissolving blockages threatening to 
destroy regions of the brain that the first patient to get it, a 
67-year-old man, regained the ability to walk and talk half an hour 
after it started flowing through his veins.

"The nurses at the bedside started crying. It was very dramatic," 
recalled Dr. William Barsan, who treated him.

TPA remains the sole drug approved for strokes. Yet only about 3 percent 
of victims get it.

Usually that's because they don't seek help until it's too late for the 
drug to do any good - three hours after symptoms start.

However, fresh research documents disturbing problems that keep this 
lifesaving treatment from reaching the roughly one in five stroke 
victims who do seek help in time. Studies presented at an American 
Stroke Association conference last week found that:

- Operators answering phones at hospitals often don't recognize stroke 
symptoms and discourage callers from coming in for help.

- Ambulances routinely take people to the nearest hospital instead of 
one with the necessary equipment and expertise to give TPA.

- Emergency room doctors are afraid of the drug's potentially serious 
side effects, and are unwilling to use it even when test results clearly 
show they should.

- Even specialized stroke centers designed to speed the drug to patients 
are missing many chances to get it right.

"It's like we've built a cascade of system failures here. Every place 
along the stream is another place something can go wrong," said Dr. 
Larry Goldstein, director of Duke University Medical Center's stroke 
program and member of a task force aimed at improving the situation.

The courts may provide added incentive to do so: Hospitals increasingly 
fear lawsuits if they fail to give the drug in time.

The consequences of missed opportunities are huge. Stroke is the third 
leading cause of death in the United States, behind heart disease and 
cancer. It's a chief reason for disability and forces many people to 
spend their final days in nursing homes, unable to walk, talk or see as 
they once could.

About 700,000 strokes occur each year, and nine out of 10 are due to a 
clot. Little could be done for them until doctors tried TPA, a 
medication used to dissolve clots causing heart attacks, for stroke.

The 1995 study, funded by the federal government, proved that it worked. 
Stroke victims treated with TPA were twice as likely to have a good 
outcome as those who were not. The Food and Drug Administration approved 
it for stroke the next year, and a move grew to treat strokes as "brain 
attacks," emergencies requiring swift treatment to prevent permanent 
damage.

Dr. Lee Schwamm, associate director of Massachusetts General Hospital's 
stroke program, called it a landmark event. "It signaled the end of 
therapeutic nihilism, the idea that if you were having a stroke it was 
just too bad, that you ought to go in a dark room and come out when it's 
over."

However, there is a dark side to this miracle-working medication. About 
6 percent of stroke patients who get it develop bleeding in the brain, 
which is fatal half the time. This can be avoided by not giving it to 
those with bleeding ulcers, very high blood pressure or certain other 
conditions.

But many emergency room doctors have been afraid to give TPA without 
neurologists to back up their judgment, and most hospitals don't have 
neurologists in the ER.

Studies show the consequences.

Dr. Toby Gropen, neurology chief at Long Island College Hospital in 
Brooklyn, examined what happened at 14 New York hospitals participating 
in a state program to boost stroke care. They more than doubled TPA use, 
but from a mere 2.4 percent to 5.2 percent.

"We're moving in the right direction. It's a start," he said.

Schwamm studied more than 21,000 patients treated at 99 hospitals 
participating in the stroke association's "Get With the Guidelines" 
campaign. When it started, only one-third of the most ideal candidates 
for TPA were getting it. That improved to 61 percent a year later, but 
that meant four out of 10 still missed out.

Barsan, chief of emergency medicine at the University of Michigan, and 
the American College of Emergency Physicians surveyed 1,105 ER doctors 
on their willingness to use TPA.

"Even under ideal conditions where we told physicians, 'you've got a 
valid CAT scan which shows there's no bleeding, there aren't any snakes 
under the rocks,' 40 percent said they were unlikely or unwilling to 
treat those patients," he said.

There are problems before patients arrive, too. Dr. Brent Jarrell of 
Cabell Huntington Hospital in West Virginia studied how hospital 
operators and helplines in several states responded to hypothetical 
calls describing classic stroke symptoms.

"Roughly 25 percent of the people were referred back to their primary 
care doctor," he said. "The kind of the feeling, when you talk to them, 
is that they were trying to keep people away from the hospital."

One in five operators couldn't identify a single stroke warning sign.

Many efforts are under way to improve things. Last year, the Joint 
Commission for Accreditation of Healthcare Organizations started 
accrediting stroke centers meeting strict standards, such as seeing 
every patient within five minutes of arrival. So far, 88 hospitals in 28 
states have earned the title and hundreds more are seeking it.

Some states - Florida, New York, Maryland and Massachusetts - have their 
own stroke center criteria, and some regions require EMS programs to 
take patients to the nearest stroke center instead of the closest hospital.

Stroke centers are also required to do community education to boost 
awareness of symptoms.

Unlike heart attacks, "stroke is almost never painful," so people often 
don't seek help, said Dr. Joseph Broderick, a University of Cincinnati 
neurologist. Signs like dizziness or numbness in an arm may be chalked 
up to things like sleeping in a funny position.

The stroke association task force issued a detailed plan last week for 
how hospitals and communities can improve stroke care.

An independent panel also recently re-analyzed information from the 
landmark 1995 study to more firmly establish the risk of side effects 
that so troubled emergency room doctors. Its conclusion: the drug's 
risks were smaller and its benefits even greater than the study 
originally found.

Stroke experts believe TPA use will rise as doctors become confident in 
their ability to pick the right patients to get it. But the only way to 
develop such judgment, they say, is to start using the drug.

---

On the Net:

Stroke information: www.strokeassociation.org

List of stroke centers: http://www.jcaho.org/dscc/psc/index.htm

AP-ES-02-05-05 1252EST

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