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(Stroke. 2001;32:2439.)
© 2001 American Heart Association, Inc.

Letters to the Editor

Racism and tPA Use in African-Americans

Andrew Evans, BSc, MRCP; Steven Duckworth, RGN Lalit Kalra, MD, PhD, FRCP

Guy’s, King’s, and St Thomas’ School of Medicine, London, United Kingdom

To the Editor:

The investigation of Johnston et al¹ into the influence of ethnicity on thrombolysis raises the spectre of racism in health service provision. However, as shown in the case of cardiac catheterization after myocardial infarction, racism is not always the reason for differences in treatment.²

Although the authors used a simple dichotomous definition of stroke severity in their regression analysis, they did not account for stroke subtype (or National Institutes of Health Stroke Scale [NIHSS] score). The proportion of ischemic stroke due to small-vessel disease in African-Americans is 52% compared with 25% in whites.³ Lacunar strokes tend to be less severe (maximum NIHSS of 10) and have a better prognosis than cortical ischemic strokes.⁴ The authors’ Table 2 demonstrates that despite American Heart Association guidelines, physicians are reluctant to give tPA to patients with less-severe stroke (only 8% of all eligible patients). Furthermore, physicians may not offer thrombolysis to those with suspected small-vessel stroke on pathophysiological grounds.⁵ This is in spite of no differential effect found in the NINDS study⁶ and that initial lacunar syndromes poorly predict eventual lacunar stroke.⁷

White patients arrived in the emergency department sooner than African-Americans. Although the percentage arriving within 3 hours was similar, a more realistic criterion for eligibility would be 2.5 hours, given that imaging, examination, and consent to treatment must all be completed prior to administration.

Another possible explanation is mistrust of health services. Even a few minutes’ prevarication can result in the 3-hour time window being exceeded. This may not be recorded . . . [Full Text of this Article]

S. Claiborne Johnston, MD, PhD; Leslie A. Gillum, MD, MPH Wade S. Smith, MD, PhD

This article has been cited by other articles:

				J. P. Stansbury, H. Jia, L. S. Williams, W. B. Vogel, and P. W. Duncan Ethnic Disparities in Stroke: Epidemiology, Acute Care, and Postacute Outcomes Stroke, February 1, 2005; 36(2): 374 - 386. [Abstract] [Full Text] [PDF]