3 Clinical Implications for Alteplase Criteria Update

APRIL 11, 2016
When the American Heart Association and the American Stroke Association first issued a joint scientific statement describing the rationale for the new inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke (AIS), I was unsure about the immediate impact that it would have on clinical practice.
 
Since it wasn’t a clinical guideline, I assumed that it would simply spark discussion and debate until the next iteration of AIS guidelines were published. Based on my clinical experience, however, it seems as though the perceived clarification of certain inclusion and exclusion criteria had an immediate impact, specifically in the following areas.
 
1. Alteplase Use in Stroke Mimics
Stroke mimics are nonvascular, nonembolic conditions that manifest similarly to AIS. Common mimics arise from certain psychogenic sources, conversion disorders, or toxic metabolic processes.
 
Prior to the scientific statement, patients presenting with stroke mimics weren’t eligible for alteplase because, well, they weren’t having a stroke. But because stroke mimics may take an extended amount of time to diagnose, and the risk for intracranial hemorrhage is low, the scientific statement recommends administering alteplase in this setting (Class IIa; Level of Evidence B).
 
The clinical implication has been an increase in the frequency of alteplase administration to this patient population, with further investigation into the etiology of the presenting symptoms occuring later on. In plain terms, alteplase is now being administered to patients who aren’t experiencing an AIS.
 
2. Alteplase Use in Rapidly Resolving or Minimal Neurological Deficit
Patients with rapidly resolving or minimal neurological deficit had previously been excluded from receiving alteplase, or at least left up to physician’s discretion. This population includes those with transient ischemic attacks or NIH Stroke Scale International scores under 4.
 
Now, patients with rapidly resolving stroke symptoms may be eligible for alteplase (Class IIa; Level of Evidence A), as well as patients with minor yet disabling stroke symptoms (Class I; Level of Evidence A).
 
3. Perceived Changes in Blood Pressure Criteria
Some alteplase exclusion criteria are erroneously thought to have been changed. The most common misconception is that alteplase may now be given despite blood pressures above 185/110, but that just isn’t the case.
 
Blood pressure must still be controlled, and reasonable measures include administration of intravenous labetalol or nicardipine. However, a patient's blood pressure may be elevated as a result of several intraveous catheters being placed, foley catheters being inserted, or clinicians rushing through exams to meet door-to-needle times. Calm yet swift treatment can work wonders in making patients feel more comfortable in very stressful situations.
 
The pharmacist’s role is as important as ever to quell the “fire, ready, aim” approach that seems to be the standard for AIS treatment.
 
Reference
Demaerschalk BM, et al. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47: 581-641.

Craig Cocchio, PharmD
Craig Cocchio, PharmD
Craig Cocchio, PharmD, BCPS, is an Emergency Medicine Clinical Pharmacist at Trinity Mother Frances Hospital in Tyler, Texas. Follow on Twitter @iEMPharmD and on his blog at empharmd.blogspot.com
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