Debate over thrombolytics for acute ischemic stroke

[JacobMcCandles]

I had always assumed stroke care would follow MI care but it seems the pharmaceutical industry has intervened. Like many things in medicine, the best time to intervene was years ago before the event happened.

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[VA Hopeful Dr]

I had always assumed stroke care would follow MI care but it seems the pharmaceutical industry has intervened. Like many things in medicine, the best time to intervene was years ago before the event happened.

Make mounjaro cheaper, get rid of the increasing irrational fear of statins, and get everyone to stop smoking and I can cut the stroke rate by half in the next 20 years.

 

[JacobMcCandles]

Make mounjaro cheaper, get rid of the increasing irrational fear of statins, and get everyone to stop smoking and I can cut the stroke rate by half in the next 20 years.

In my ideal world, more meds wouldn’t be the answer.

 

[sloh]

Maybe not statins but I wouldn’t underestimate how effective GLP-1 agonists are

 

[Porfirio]

Make mounjaro cheaper, get rid of the increasing irrational fear of statins, and get everyone to stop smoking and I can cut the stroke rate by half in the next 20 years.

This reminds me of my hospital’s phone call holding voice recording that claims patients need to seek help at the hospital because 40% of all strokes are preventable.

 

[VA Hopeful Dr]

In my ideal world, more meds wouldn’t be the answer.

Absolutely agree.

However, history has shown us again and again that most patients won't/can't lose weight on their own. So its either meds or functionally nothing.

 

[TooMuchResearch]

Absolutely agree.

However, history has shown us again and again that most patients won't/can't lose weight on their own. So its either meds or functionally nothing.

Sure plus it can be hard moving the needle aggressively on Apo B without drugs.

 

[RustedFox]

Make mounjaro cheaper, get rid of the increasing irrational fear of statins, and get everyone to stop smoking and I can cut the stroke rate by half in the next 20 years.

In my ideal world, more meds wouldn’t be the answer.

Maybe not statins but I wouldn’t underestimate how effective GLP-1 agonists are

This reminds me of my hospital’s phone call holding voice recording that claims patients need to seek help at the hospital because 40% of all strokes are preventable.

Look, I love y'all.
But we all know that using a drug to fix the problems caused by a drug, without addressing the use of the first drug (which often requires Draconian changes to life) is just the "cigarette/albuterol machine".

 

[thegenius]

Make mounjaro cheaper, get rid of the increasing irrational fear of statins, and get everyone to stop smoking and I can cut the stroke rate by half in the next 20 years.

I don't think GLP-1's should be paid for by drug prescription / insurance premiums. Obesity is a medical problem that can universally be treated without drugs in 99.5% of people.

I agree with your other statement that people won't / can't lose weight on their own. But that doens't mean I need to partially pay for their mounjaro. For fricking sake we are steadily absolving people of all health care moral hazard in our society. I think if you smoke your premiums should go up, if you are fat they should go up, and if you eat a subway sandwiche with a side of cheetoes every other day, your premiums should go up.

Re statins: Maybe there is an irrational fear, but my cursory knowledge of them is that there is emerging evidence they really don't work well in many cases and that they are overprescribed.

 

[thegenius]

Look, I love y'all.
But we all know that using a drug to fix the problems caused by a drug, without addressing the use of the first drug (which often requires Draconian changes to life) is just the "cigarette/albuterol machine".

charge 'em more $$

 

[JacobMcCandles]

Re statins: Maybe there is an irrational fear, but my cursory knowledge of them is that there is emerging evidence they really don't work well in many cases and that they are overprescribed.

Under current practice, at some point, everybody of a certain age regardless of their lipid panel and blood pressure (could be the best lipid panel you’ve ever seen with a perfect blood pressure) will be recommended a statin. Those kinds of blanket recommendations don’t pass my personal smell test.

 

[VA Hopeful Dr]

I don't think GLP-1's should be paid for by drug prescription / insurance premiums. Obesity is a medical problem that can universally be treated without drugs in 99.5% of people.

I agree with your other statement that people won't / can't lose weight on their own. But that doens't mean I need to partially pay for their mounjaro. For fricking sake we are steadily absolving people of all health care moral hazard in our society. I think if you smoke your premiums should go up, if you are fat they should go up, and if you eat a subway sandwiche with a side of cheetoes every other day, your premiums should go up.

Re statins: Maybe there is an irrational fear, but my cursory knowledge of them is that there is emerging evidence they really don't work well in many cases and that they are overprescribed.

If you smoke your premiums DO go up. Its the one health issue that that ACA allows for.

You'll notice that I didn't say "make insurance cover mounjaro". I said to make it cheaper. $1200/month (or even $600 with a coupon) is absurd.

 

[VA Hopeful Dr]

Under current practice, at some point, everybody of a certain age regardless of their lipid panel and blood pressure (could be the best lipid panel you’ve ever seen with a perfect blood pressure) will be recommended a statin. Those kinds of blanket recommendations don’t pass my personal smell test.

Yeah I don't care what your ASCVD risk score is, if you don't have diabetes or vascular disease I'm not prescribing a statin if your HDL is normal and your LDL is below 100.

Basically if you receive medical care regularly and haven't been started on a statin by around age 75, I'm not going to start one barring a second indication (MI at 78, for example).

 

[sloh]

Look, I love y'all.
But we all know that using a drug to fix the problems caused by a drug, without addressing the use of the first drug (which often requires Draconian changes to life) is just the "cigarette/albuterol machine".

We are both into nutrition and resistance training, so I do think in general lifestyle intervention/modifications are the best approach. I think I've just been absolutely burned too many times where these lifestyle intervention recs meet eyerolls—not just patients but friends (often these are physicians as well), colleagues, extended family members, etc.

 

[RustedFox]

We are both into nutrition and resistance training, so I do think in general lifestyle intervention/modifications are the best approach. I think I've just been absolutely burned too many times where these lifestyle intervention recs meet eyerolls—not just patients but friends (often these are physicians as well), colleagues, extended family members, etc.

See; this... THIS is the PRECISE moment (the eyeroll) that you need to double down on our position of "austerity breeds excellence". There's many strategies to do it.

The one that I find has the most "impact over intent" is getting the man to realize that he wants to protect his family.

"Dude, you and your family are in a car crash. Car is on its side. A small fire starts. Help is 20-30 mins away. You hear: 'Dad, I can't move. Help me. Get me out.' You need to free your family. Only you. You're gonna need some muscles. Better get them NOW."

 

[VA Hopeful Dr]

See; this... THIS is the PRECISE moment (the eyeroll) that you need to double down on our position of "austerity breeds excellence". There's many strategies to do it.

The one that I find has the most "impact over intent" is getting the man to realize that he wants to protect his family.

"Dude, you and your family are in a car crash. Car is on its side. A small fire starts. Help is 20-30 mins away. You hear: 'Dad, I can't move. Help me. Get me out.' You need to free your family. Only you. You're gonna need some muscles. Better get them NOW."

I would legitimately love to see a study that looks into this. Could use motivational interviewing in the traditional sense in one arm and the other arm we'll call it rustedfox's tough love.

 

[Apollyon]

See; this... THIS is the PRECISE moment (the eyeroll) that you need to double down on our position of "austerity breeds excellence". There's many strategies to do it.

The one that I find has the most "impact over intent" is getting the man to realize that he wants to protect his family.

"Dude, you and your family are in a car crash. Car is on its side. A small fire starts. Help is 20-30 mins away. You hear: 'Dad, I can't move. Help me. Get me out.' You need to free your family. Only you. You're gonna need some muscles. Better get them NOW."

Just one little thing. I was a firefighter for 9 years. Do you know how many MVCs had a fire?

I'll give you a hint: it's less than 1.

That's anecdotal, but, I would ask @southerndoc his experience, and too bad foughtfyr and DocB aren't around anymore.

 

[RustedFox]

I would legitimately love to see a study that looks into this. Could use motivational interviewing in the traditional sense in one arm and the other arm we'll call it rustedfox's tough love.

Honestly, bro - I don't know where along the way we Americans lost the masculine desire for physical excellence, but we did. Guys will walk out of the theater after a spy movie and think that they're cool, crafty, clever, and can get the best of the bad guy in a scuffle - then go stuff their faces with fried food and a six pack of beer, placing the paper plate on their abdomentable while they sit on their couch.

Directing my criticisms at myself, I know what I need to do next. I need a martial arts class of some variety.

Just one little thing. I was a firefighter for 9 years. Do you know how many MVCs had a fire?

I'll give you a hint: it's less than 1.

That's anecdotal, but, I would ask @southerndoc his experience, and too bad foughtfyr and DocB aren't around anymore.

All of them have a fire in my thought experiment. Get out of here with your empiric facts. They don't help me to illustrate my point or stoke the desire for self-reliance in the man in question. I say this with love, bro.

 

[FiremedicMike]

About 10 years ago a local hospital system decided to launch a stroke truck and were trying to convince me to add them into our ems response matrix. Limited view CT and their only claim to fame was they could push thrombolytics sooner than in the ED. Any patient not appropriate for thrombolytics was punted back to EMS who would then transport to the ED for the stroke work up to start all over again.. At that time I found stats from AHA that showed during meta analysis that only about 2% of stroke patients get thrombolytics.

When I took this back to the stroke truck team and asked for their data on administration frequency, scene times, and % of time they punt back to EMS, they refused to provide that data. I told them I’m not delaying treatment for 98% of the stroke population so that 2% could get a “maybe will help” drug 10 minutes sooner - oh it’s pertinent to add that there’s several stroke centers in town and you’re never more than 10 minutes from one..

 

[FiremedicMike]

Just one little thing. I was a firefighter for 9 years. Do you know how many MVCs had a fire?

I'll give you a hint: it's less than 1.

That's anecdotal, but, I would ask @southerndoc his experience, and too bad foughtfyr and DocB aren't around anymore.

Car fires always explode in the movies.. number of cars I’ve seen explode in coming up on 3 decades = 0

 

[JacobMcCandles]

Car fires always explode in the movies.. number of cars I’ve seen explode in coming up on 3 decades = 0

*The Fast and The Furious* NOS!!!!

 

[Jabbed]

Car fires always explode in the movies.. number of cars I’ve seen explode in coming up on 3 decades = 0

They always explode if you shoot them in the gas tank inlet à la Grand Theft Auto rules.

 

[FiremedicMike]

They always explode if you shoot them in the gas tank inlet à la Grand Theft Auto rules.

Another universal truth of movies - if they start bleeding from the mouth, they're dead.. if they don't start bleeding from the mouth, they can probably toss a 4x4 on their wound and continue the fight..

 

[Jabbed]

Another universal truth of movies - if they start bleeding from the mouth, they're dead.. if they don't start bleeding from the mouth, they can probably toss a 4x4 on their wound and continue the fight..

Obviously, bleeding from the mouth means that it’s internal bleeding.

My (neurologist) wife’s pet peeve is when they get shot right in the brachial plexus with a “shoulder wound” and are totally fine.

 

[VA Hopeful Dr]

Honestly, bro - I don't know where along the way we Americans lost the masculine desire for physical excellence, but we did. Guys will walk out of the theater after a spy movie and think that they're cool, crafty, clever, and can get the best of the bad guy in a scuffle - then go stuff their faces with fried food and a six pack of beer, placing the paper plate on their abdomentable while they sit on their couch.

Directing my criticisms at myself, I know what I need to do next. I need a martial arts class of some variety.

I'm not sure how universal that ever was. I think our biggest culprit is a combination of much more plentiful food for everyone, and much more sedentary jobs with a side helping of much more calorie dense food.

 

[Pudortu]

I used to be a big anti-TPA guy and would quote David Newman all the time. I think everyone has brought up great points. What's interesting is the NNT website has (what appears to me) contradicting opinions.

Thrombolytics for Stroke – TheNNT

thennt.com

Tissue Plasminogen Activator (tPA) For Acute Ischemic Stroke – TheNNT

thennt.com

It looks like the NNT website now promotes TPA? Maybe I am reading this wrong.

 

[Jabbed]

I used to be a big anti-TPA guy and would quote David Newman all the time. I think everyone has brought up great points. What's interesting is the NNT website has (what appears to me) contradicting opinions.

Thrombolytics for Stroke – TheNNT

thennt.com

Tissue Plasminogen Activator (tPA) For Acute Ischemic Stroke – TheNNT

thennt.com

It looks like the NNT website now promotes TPA? Maybe I am reading this wrong.

Tissue Plasminogen Activator (tPA) For Acute Ischemic Stroke (2021) – TheNNT

“This is the third NNT summary of thrombolytics for acute ischemic stroke. The first gave thrombolytics, as a class, a "red color recommendation: no benefit." The second gave alteplase, a single agent, a "green color recommendation: benefit>harm." As no relevant trials were published between the two, both author groups examined essentially the same data and arrived at opposing conclusions. We believe it would be hubris to presume this third summary will arrive at the one true answer. We focus, therefore, on the uncertainty we believe leads to conflicting interpretations.”

 

[Pudortu]

Tissue Plasminogen Activator (tPA) For Acute Ischemic Stroke (2021) – TheNNT

“This is the third NNT summary of thrombolytics for acute ischemic stroke. The first gave thrombolytics, as a class, a "red color recommendation: no benefit." The second gave alteplase, a single agent, a "green color recommendation: benefit>harm." As no relevant trials were published between the two, both author groups examined essentially the same data and arrived at opposing conclusions. We believe it would be hubris to presume this third summary will arrive at the one true answer. We focus, therefore, on the uncertainty we believe leads to conflicting interpretations.”

Thanks a ton. Didn't even see the 3rd one.

 

[hoot504]

There's also been a move toward punting this decision to neurology as the decision tree becomes more complex re: windows/workup/neurointervention etc. It has basically migrated outside EM scope other than activating stroke alerts whenever the triage nurse might put something in the chart to that effect.

Five posts in and this is the on-the-ground reality.

I've worked at 5 hospitals since residency. At all but one a neurologist (either in person or via tele) is ultimately the one to hand down the thrombolytic go/no-go for launch. Even the relatively resource poor BFE hospital I locums at has rapidly available teleneuro who would give the rec. As such, it really isn't my battle to fight.

 

[DocEspana]

I’ve worked many years and at my level 2 interventional stroke center I made tpa decision in isolation. Interventional was contacted for lvo. Have not had neurologist make tpa decision for me since residency. 9+ years out. On west coast.

I think my neurologists dont trust me (the larger EM "me") to make that decision. They know TPA/TNK utilization will plummet by like 75% if they leave us in charge of it.

 

[DocEspana]

Make mounjaro cheaper,

yes

get rid of the increasing irrational fear of statins,

I still have questions about the risk of inducing diabetes as being such a bad outcome in someone who has 'just' HLD beforehand, but I have chilled out enough to keep that concern to myself

and get everyone to stop smoking and I can cut the stroke rate by half in the next 20 years.

yeah. it would.

 

[DocEspana]

I don't think GLP-1's should be paid for by drug prescription / insurance premiums. Obesity is a medical problem that can universally be treated without drugs in 99.5% of people.

I agree with your other statement that people won't / can't lose weight on their own. But that doens't mean I need to partially pay for their mounjaro. For fricking sake we are steadily absolving people of all health care moral hazard in our society. I think if you smoke your premiums should go up, if you are fat they should go up, and if you eat a subway sandwiche with a side of cheetoes every other day, your premiums should go up.

Re statins: Maybe there is an irrational fear, but my cursory knowledge of them is that there is emerging evidence they really don't work well in many cases and that they are overprescribed.

GLP-1s do more than just 'make you skinny'. They seem to blunt the urges for all vices. Not just hunger. Smoking. Alcohol. stimulant addiction (havent seen anything suggesting opiate addiction benefits), GAMBLING. They are an anti-vice machine and, at a currently ridiculous price, they can change your entire risk profile for all sorts of chronic maladies across the board.

And lets me honest, letting people keep more years of good CV health, more toes, and maybe deprive online casinos of more cash will lead to so much money saved for the nation just on healthcare costs for long term issues that eventually falls on medicare/aid. Also, less gambling vices.

 

[Brigade4Radiant]

No matter what happens to patients, the doctor will be held liable similar to the doctor when the patient went to the chiropractor or if they eat a lot

 

[thegenius]

GLP-1s do more than just 'make you skinny'. They seem to blunt the urges for all vices. Not just hunger. Smoking. Alcohol. stimulant addiction (havent seen anything suggesting opiate addiction benefits), GAMBLING. They are an anti-vice machine and, at a currently ridiculous price, they can change your entire risk profile for all sorts of chronic maladies across the board.

And lets me honest, letting people keep more years of good CV health, more toes, and maybe deprive online casinos of more cash will lead to so much money saved for the nation just on healthcare costs for long term issues that eventually falls on medicare/aid. Also, less gambling vices.

I've heard this argument too. My sister says that GLP-1s get rid of her "food noise" in her brain.

I guess society has had an Ozempic deficiency for decades!

The proof will be when insurance companies lower your premiums if you are on a GLP-1. Until then, I vote for society not paying for them.