Tissue plasminogen activator for ischaemic stroke: highly effective, reasonably safe and grossly underused

Australian health systems must rise to the challenge of providing thrombolysis to more stroke patients

The substantial benefits and relative safety of tissue plasminogen activator (tPA) for acute ischaemic stroke within 3 hours of symptom onset have been accepted by stroke clinicians around the world.1 It is one of the most effective treatments in acute medicine, with a 30% increase in excellent outcomes and a “number needed to treat” for clinical improvement as low as three patients.2 A European register of 6483 patients (SITS-MOST, Safe Implementation of Thrombolysis in Stroke Monitoring Study) indicated that tPA is safe and effective, even when used in relatively inexperienced centres.3 The clinical benefits overwhelm a small rate of bleeding complications, chiefly symptomatic haemorrhagic transformation of the infarct. The rate of symptomatic intracerebral haemorrhage was actually lower in this large register than in the earlier randomised clinical trials.3 Small Australian tPA audits have confirmed these conclusions.4,5 Based on level 1 evidence, the therapy was licensed in Australia in 2003, and is recommended in Australian, North American and European stroke guidelines.6 However, despite this overwhelming information, probably some thousands of Australian patients are effectively denied tPA each year.7 This is a major challenge for our health system.