To the Editor: I am concerned about the conclusions
of the Editorial by Dr Caplan1 that accompanied
2 studies on the use of thrombolytic therapy for acute stroke. The first article2 reported a mortality rate of 10% among 1658 patients
during the initial hospitalization, and 27.2% of patients had one or more
serious complications. The second article3 reported
that 111 (51.4%) of 216 patients who were treated with alteplase had a lack
of improvement at 24 hours, 43 patients (20%) had died at 3 months, and 75
(44%) of 170 survivors had poor outcomes. The Editorial, although cautious,
concluded that more patients should be given thrombolytic treatment, and that
there is an urgent need to transport patients to stroke centers more quickly.
There is no suggestion that a moratorium be placed on lytic therapy for acute
stroke in community hospitals, which is a conclusion that could have been
drawn from these studies. By protocol, thrombolytic therapy is to be initiated
within 3 hours, but the physician making a treatment decision in such patients
cannot clinically tell whether the patient is having a transient ischemic
attack or a reversible ischemic neurological deficit rather than a stroke
with symptoms persisting beyond 1 to 7 days. It may be that some of these
patients would be better off if given an aspirin and left alone for 24 hours.
Complications associated with a disease may be more acceptable to patients
and families than complications associated with treatment.
Svoboda JJ. Thrombolysis for Acute Stroke. JAMA. 2005;293(4):421-422. doi:10.1001/jama.293.4.421-c