Thrombolysis in Stroke: a Medicolegal Quagmire
To the Editor:
In a recent article,1 Dr Weintraub refers to the American Heart Association (AHA) 2000 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care2 asserting that “The current guidelines are outdated and do not even include the benefit of MRI and diffusion-weighted imaging as well as the increased mortality associated with older age and large infarcts, etc. We need to re-establish trust and confidence in our professional societies which can only occur with a definitive new trial and updated protocol. Because the medical designation of Class I status is controversial…”
The development of the AHA’s stroke-related guidelines is one of the responsibilities of the Stroke Council. We would point out that 2 American Stroke Association (ASA)/AHA Stroke Council evidence-based guidelines reviewing thrombolytic therapy were published subsequent to the document cited by Dr Weintraub, which specifically discuss factors that may affect the efficacy of intravenous recombinant tissue plasminogen activator as well as the role of neuroimaging technologies, including MRI.3,4
The Stroke Council has developed policies to ensure that its guidelines are both impartial and up-to-date.5 These include a complete review and revision of 6 “flagship” stroke guideline documents to be published every 3 years with interim “Practice Advisories” based on new developments that alter a previous recommendation. Another revision of the Guidelines for the Early Management of Acute Ischemic Stroke is currently under review. The Stroke Council’s Guideline Development Manual detailing the policies and procedures to be followed is available online at the Stroke Council web-page (http://www.americanheart.org/presenter.jhtml?identifier=1197).
Stroke Council Guidelines adhere to the highest standards. Indeed, the value of the Council’s 2 most recent guidelines was independently affirmed by the American Academy of Neurology.6,7 The public and healthcare providers can place their trust and confidence in the ASA/AHA Stroke Council’s guidelines.
Dr Goldstein is Chair of the AHA Stroke Council Leadership Committee. Dr Saver is Chair of the Stroke Council’s Scientific Statement Oversight Committee.
Weintraub MI. Thrombolysis in stroke: a medicolegal quagmire. Stroke. 2006; 37: 1917–1922.
The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 7: The era of reperfusion: Section 2: Acute stroke. Circulation. 2000; 102 (Suppl): I-102–I-122.
Adams HP, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatowski TG, Hademenos GJ. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003; 34: 1056–1083.
Adams HP, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update: a scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke. 2005; 36: 916–923.
Saver J, Goldstein LB. The new standing committee policy of the American Stroke Association Stroke Council. Stroke. 2006 ;37: 753.
Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie KL, Goldstein LB, Gorelick P, Halperin J, Harbaugh RE, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Schwamm LH, Tomsick T. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke. Stroke. 2006; 37: 577–617.
Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, Culebras A, Degraba TJ, Gorelick PB, Guyton JR, Hart RG, Howard G, Kelly-Hayes M, Nixon JV, Sacco RL. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council. Stroke. 2006; 37: 1583–1633.