In the United States in 2022, stroke accounted for 1 in 6 deaths related to cardiovascular disease, according to the Centers for Disease Control and Prevention (CDC). The incidence rate of stroke experienced a slight decrease from 41.1 per 100,000 in 2021 to 39.5 per 100,000 in 2022. Ischemic strokes make up approximately 87% of all strokes, with around 30% of acute ischemic strokes involving a large vessel occlusion (LVO). LVO plays a significant role in 64% of cases resulting in moderate-to-severe disability from stroke at 3 months and over 95% of stroke-related deaths at 6 months. These statistics underscore the significant impact of stroke on public health and highlight the critical need for ongoing research and optimal management strategies for this condition.
This Guidelines Side-By-Side article offers a comprehensive comparison of the current clinical practice guidelines from the American Heart Association/American Stroke Association (AHA/ASA) and the clinical policy from the American College of Emergency Physicians (ACEP). By analyzing these recommendations, this article aims to provide healthcare providers with valuable insights and best practices for the management of acute ischemic stroke. This evidence-based approach seeks to improve health outcomes for individuals affected by this complex condition.
Titles of Comparison:
| Titles | Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke | Clinical Policy: Use of Thrombolytics for the Management of Acute Ischemic Stroke in the Emergency Department |
|---|---|---|
| Society | American Heart Association/American Stroke Association (AHA/ASA) | American College of Emergency Physicians (ACEP) |
| Publication Date | October 30, 2019 | September 26, 2024 |
| Objective | The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. | This clinical policy from the American College of Emergency Physicians (ACEP) is the revision of a clinical policy approved in 2015 addressing a critical question regarding the use of thrombolytics for the management of acute ischemic stroke. |
| Target Population | The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. | This guideline is intended forphysicians working in emergency departments (EDs). |
| Methodology | Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council’s Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. | This American College of Emergency Physicians (ACEP) clinical policy was developed by emergency physicians with input from medical librarians and a patient safety advocate; is based on a systematic review and critical descriptive analysis of the medical literature; and is reported in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. |
| Graded Strength of Recommendations | Yes | Yes |
| Graded Level of Evidence | Yes | Yes |
| Systematic Review Conducted | Yes | Yes |
| Literature Review Conducted | Yes | Yes |
| COIs & Funding Source(s) Disclosed | Yes | Yes |
| Full-text | Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke | Clinical Policy: Use of Thrombolytics for the Management of Acute Ischemic Stroke in the Emergency Department |
| Summary | Early Management of Patients With Acute Ischemic Stroke | Use of Thrombolytics for the Management of Acute Ischemic Stroke in the Emergency Department |
Comparison of Key Points on Thrombolytics
| 2019 Update AHA/ASA | ACEP Clinical Policy | |
|---|---|---|
| Time Window for rtPA Use | Within 4.5 hours (with some consideration for patients outside this window based on newer studies). | Within 3 to 4.5 hours of symptom onset. |
| Exclusion Criteria | Standard exclusion criteria (e.g., active bleeding, severe hypertension, recent surgery). | More detailed exclusion criteria, including recent trauma, recent surgery, and more specific hypertension thresholds. |
| Imaging | Neuroimaging required to confirm ischemic stroke (CT/MRI). | CT or MRI required to confirm ischemic stroke. |
| Monitoring After Administration | Emphasis on monitoring for intracranial hemorrhage (ICH) and other complications (e.g., blood pressure management). | Focus on monitoring for ICH, blood pressure management, and complications in the ED. |
| Extended Window for Thrombolysis | Evidence for using rtPA beyond 4.5 hours in select patients, especially with thrombectomy consideration. | Focus on a strict 3-4.5 hour window, with limited extension. |
Management Overview
The 2019 Update to the AHA/ASA guidelines provides recommendations for the use of intravenous tissue plasminogen activator (rtPA) for eligible patients within 4.5 hours of symptom onset. Key points include:
- Use of rtPA:
- rtPA is recommended for patients with AIS within 4.5 hours of symptom onset who meet eligibility criteria (no contraindications like active bleeding, severe hypertension, or recent surgery).
- Inclusion Criteria: Patients who have symptoms of acute ischemic stroke with a diagnosis confirmed by neuroimaging (CT/MRI). The benefit of rtPA is greatest when administered as soon as possible after symptom onset, but it can still be beneficial within the 4.5-hour window.
- rtPA is recommended for patients with AIS within 4.5 hours of symptom onset who meet eligibility criteria (no contraindications like active bleeding, severe hypertension, or recent surgery).
- Thrombectomy and Thrombolytics:
- While the focus of the 2019 update extends to thrombectomy for patients with large vessel occlusion (LVO) within 24 hours of symptom onset, rtPA remains the first-line treatment for ischemic strokes within the first 4.5 hours in patients who do not meet the criteria for thrombectomy.
- Safety and Monitoring:
- After administering rtPA, careful monitoring is important, especially to assess for complications like intracranial hemorrhage (ICH). This includes regular neurological checks and imaging to assess bleeding risk.
- Extended Window for rtPA:
- The guidelines include a small body of evidence for using rtPA beyond 4.5 hours in select patients (under specific clinical trials), but the main recommendation is within the 4.5-hour time window.
- Imaging:
- Neuroimaging is used to exclude hemorrhagic strokes and to guide decision-making on the use of rtPA in patients with AIS.
The ACEP Clinical Policy provides practical guidance specifically for emergency departments in the rapid initiation of rtPA for AIS. Key points include:
- Use of rtPA:
- Similar to the AHA/ASA guidelines, rtPA is recommended within 3 to 4.5 hours of symptom onset for eligible patients.
- Inclusion Criteria: The ACEP policy stresses the importance of confirming ischemic stroke with imaging (CT or MRI) and ensuring the patient meets criteria for thrombolysis, including no contraindications (such as active bleeding, history of hemorrhagic stroke, or severe hypertension).
- Exclusion Criteria:
- The ACEP guidelines list more detailed exclusion criteria for rtPA, including:
- Major trauma or surgery within the past 14 days.
- Known or suspected intracranial hemorrhage.
- History of intracranial hemorrhage or certain levels of hypertension.
- The ACEP guidelines list more detailed exclusion criteria for rtPA, including:
- Timing:
- The ACEP policy emphasizes the 3-4.5 hour window for thrombolytics, but acknowledges that early thrombolysis is the most effective in improving outcomes, and the sooner rtPA is given, the better the potential benefit.
- Monitoring and Safety:
- Post-administration monitoring is recommended for complications, particularly for intracranial hemorrhage (ICH). Monitoring of blood pressure is crucial, as uncontrolled hypertension increases the risk of bleeding after rtPA administration.
- Imaging:
- As with the AHA/ASA guidelines, CT or MRI is necessary to rule out hemorrhagic stroke and assess eligibility for thrombolytic therapy.
The 2019 AHA/ASA Update provides a more nuanced approach to thrombolytic use, expanding on the potential for extended windows and focusing on comprehensive care, including the role of thrombectomy.
The ACEP Clinical Policy is more specific to the emergency department setting and provides more detailed exclusion criteria and practical guidance for rtPA administration within a 3-4.5-hour window, prioritizing the rapid administration of thrombolytics in an emergency context.
In conclusion, while the AHA/ASA guidelines (2018 and 2019 updates) offer a broad, evidence-based approach, including more complex decisions about thrombectomy and extended windows, the ACEP policy is more focused on emergency department settings, emphasizing swift thrombolysis administration and detailed exclusion criteria.
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