stroke

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Promising Advance In Stroke Thrombolysis Research: Tenecteplase

Neal Parikh, MD

A recent New York Times article re-surfaced the ‘debate’ regarding alteplase (IV-tPA) for ischemic stroke.1 There are some who continue to argue that the data for IV-tPA are not convincing. In this context, and otherwise, it is worthwhile to discuss a recent study comparing tenecteplase versus alteplase among patients with large vessel occlusion.2

In this study, 202 patients presenting within the IV-tPA treatment window of 4.5 hours and with an ischemic stroke due to large vessel occlusion were randomized to receive IV-tPA versus IV-tenecteplase prior to proceeding with mechanical thrombectomy. The main outcomes relevant for this discussion are the primary outcome of substantial reperfusion (restoration of blood flow in the affected area) and the safety outcome of brain hemorrhage.

Whereas 10% of patients who had received IV-tPA achieved substantial reperfusion prior to undergoing mechanical thrombectomy, 22% achieved substantial reperfusion in the tenecteplase group. The number of brain hemorrhages was the same in both groups (5-6%).

If confirmed, this represents a tremendous advance in thrombolysis because many patients require lengthy transport to reach a center where thrombectomy can be performed. Achieving reperfusion without increased risk of hemorrhage, potentially in the field using stroke ambulances and telemedicine, could dramatically improve population-level care for this otherwise very disabling form of stroke.

Further, these data suggest support the stability of the 6% estimate of brain hemorrhage risk with IV-thrombolysis. The observation that the hemorrhage risk (5 vs 6%) was the same regardless of reperfusion rate (10 vs 22%) is intriguing – if the two are independent, is the risk of hemorrhage from thrombolysis from something other than reperfusion? Further, the results of this study will spur additional study and we will thus have contemporary, high-quality data regarding the efficacy and safety of thrombolysis.

References

  1. https://www.nytimes.com/2018/03/26/health/stroke-clot-buster
  2. Campbell, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. NEJM. 2018:378:1573-82.

Neal Parikh Headshot

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @NealSParikhMD and contributes to Blogging Stroke as a blogger.
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Women’s Heart Disease – The Interdisciplinary Road Ahead

Tanja Dudenbostel, MD

Every 80 seconds a woman dies from a heart attack or stroke. Once thought to be predominantly found in men, coronary heart disease remains the leading cause of morbidity and mortality for women in the US and worldwide. There have been significant improvements in cardiovascular mortality in women in the last two decades with narrowing of outcomes between women and men which have been attributed to improved therapy for established cardiovascular disease and to primary and secondary preventive interventions. However, women are less likely to receive evidence-based care and have worse outcomes than men. Gender differences have been recognized, but vast knowledge gaps in gender differences regarding pathophysiology, clinical presentation, diagnosis, and optimal acute and chronic treatment strategies for heart attacks and co-existing or resulting complications such as heart failure remain. The AHA Scientific Statement “Acute Myocardial Infarction in Women” provides a comprehensive review of the current evidence.
 
At the opening plenary session of the American College of Cardiology ACC.18 meeting in Orlando, Florida, the pioneer of women’s cardiology Dr. Nanette Kass Wenger gave her inspiring Simon Dack keynote lecture on Heart Disease & Women titled “Understanding the Journey-The Past, Present and Future of CVD in Women.”
 
In “Steps on the journey” Dr. Wenger gave a comprehensive review of the early beginnings and showed how far we have come. Some interesting anecdotes were also shared such as that the first women’s heart disease meeting in Iowa in the 1950s was to help women prevent heart attacks in husbands.
 
Her impactful vision on how to expand the landscape of women’s cardiovascular health research in the next decade struck a nerve with me and made me re-think some of the concepts we are applying in academic cardiology. Dr. Wenger called for an expansion of women’s cardiovascular health research to include social determinants of health as nearly 80% of heart outcomes depend on social factors. Women’s Heart Health is not solely a medical problem and clinical research cannot happen in a vacuum in the hospital. A variety of factors contribute to women’s cardiovascular health and need to be considered for maintenance of health and cure of disease. Women’s Heart Heath needs to be extended. Factors like beliefs and behaviors, the local community, economic, environmental, ethical, legislative/political, public policy – all these social determinants need to be included in heart disease research in women.
 
My take away for the future was that we cannot longer compartmentalize and that programs focusing on Women’s Heart Heath need to involve all programs available- not only cardiology. It needs to be an interdisciplinary approach to learn more about physiology, psychology and ecology of health for best outcomes and to tackle Women’s Heart Health.
 
Dr. Wenger quoted the French Victor Hugo in her inspiring lecture.
 
“There is nothing as powerful as an idea whose time has come.”
Victor Hugo
Histoire d’un crime, 1977
 

Tanja Dudenbostel Headshot

Tanja Dudenbostel is an Internist, Hypertension Specialist within Cardiology at the University of Alabama at Birmingham where I divide my time as an Assistant Professor between clinical research and seeing patients in cardiology.