Physician Knowledge of the Benefits, Risks, and Contraindications of Tissue Plasminogen Activator for Acute Ischemic Stroke
To the Editor:
Emergency room (ER) physicians and neurologists are critical in ensuring a prompt evaluation of patients arriving at the ER within 3 hours of symptom onset and in initiating therapy with tPA. Suboptimal institutional readiness for evaluating patients with acute stroke and fear about the hemorrhagic complications among neurologists are some of the factors that can limit the widespread use of tPA, as reported by Katzan et al.1 Family physicians play an important role in educating patients at risk for stroke about the warning signs of stroke and the importance of contacting 911 as soon as these appear. Limited knowledge about the benefits and an unjustified fear of the side effects may limit stroke patients’ access to this treatment. To assess physician knowledge about tPA, we carried out a survey among family physicians, ER physicians, and neurologists in London, Ontario, 1 year after the Health Protection Branch approved the use of tPA for acute ischemic stroke.2
Based on Dillman’s total design method,3 a survey was mailed to all family physicians (n=266), neurologists (n=19), and ER physicians (n=20) practicing in London, Ontario, in early January 2000. A second mailing was sent in February to those who had not responded. The lists of family doctors and neurologists were obtained from the departments of Family Medicine and Clinical Neurological Sciences at the University of Western Ontario. ER physicians were identified from the faculty directory. The survey consisted of 10 multiple-choice questions. Knowledge of contraindications was evaluated by presenting a brief clinical scenario and asking respondents if the use of tPA was contraindicated in that situation. Respondents had an option of answering “don’t know/uncertain” to each question. The percentage of correct responses for each question, sorted by specialty, was calculated.
The overall response rate was 57% (147 family physicians, 14 neurologists, and 14 ER physicians responded). Because the answers of neurologists and ER physicians were similar, they were analyzed as a single group. The Table presents the percentage of correct responses to each question sorted by specialty. When the family medicine group was divided in terms of number of years in practice (<10 [n=24] versus >10 [n=120]) the percentage of correct answers was not different (data not shown). The perceived benefit of tPA was similar between both groups; 79% of family doctors (95% CI 73 to 86) and 82% of neurologists and ER physicians (95% CI 68 to 96) agreed that tPA was beneficial for the treatment of acute ischemic stroke.
Regardless of specialty, physician awareness about the benefits, risks, indications, and contraindications of tPA for acute stroke is insufficient. Limited knowledge of the benefits and unjustified fear of the side effects may limit stroke patients’ access to this treatment. For tPA to be widely used, coordinated efforts by multidisciplinary teams focusing on patient education, rapid access to emergency care, and prompt evaluation in the ER are essential.4 These steps will take place only if physicians are fully aware of the risks and benefits of available treatments. Acute stroke teams should consider the education of their peers an integral part of their mission. Educational efforts should be specialty driven: family physicians need to know about the time constraints, benefits, and risks associated with the use of tPA; ER physicians and neurologists need to be familiar with the indications and contraindications of this therapeutic tool.
The Heart and Stroke Foundation of Ontario helped defray the costs of postage. We would like to thank Ms Eva Newhouse and Ms Rebecca Nott for their secretarial assistance.
Review of this letter was directed by Graeme J. Hankey, MD.
Katzan IL, Sila CA, Furlan AJ. Community use of intravenous tissue plasminogen activator for acute stroke: results of the Brain Matters Stroke Management Survey. Stroke. 2001; 32: 861–865.
Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York, NY: John Wiley & Sons; 1978.