Guidelines for tPA – An alternate view

Just as there is division in our specialty regarding tPA for ischemic stroke, diversity of opinion exists within the ACEP leadership ranks. Following the Board’s approval of this new clinical policy, in the spirit of transparency, ACEP leadership asked me to draft the minority opinion on this topic.

With respect to clinical guidelines, one size must fit all. When considerable controversy exists and reasonable minds can disagree on the interpretation of the available evidence, then perhaps drafting a guideline is not only impossible but also inappropriate. Development of guidelines should be a search for scientific truth, a truth that can be applied by all. The ultimate goal of any guideline is to provide guidance once the dust has settled from debate and a clear right answer has emerged. If not accepted by all, or even most, consensus has not been reached. Caution must be taken by those drafting guidelines for the many, to avoid amplification of the perspectives of the few.

ACEP’s recent clinical policy regarding the administration of tPA for ischemic stroke is an excellent example of a topic, fraught with controversy and a lack of consensus, which results in maneuvering a square peg into a round hole. Forcing premature closure and drawing early conclusions, while the clinical evidence and science are still being debated and are in evolution, is ill advised. The fact that the panel could reach consensus is less than comforting, when it is possible that at least as many experts in our field share a perspective in direct opposition to the panel’s conclusions.

I have to compliment the Clinical Policies Committee for attempting to accomplish the impossible, given a task that was unattainable. It seems that this question was asked when no reasonable consensus could possibly be reached. Spending 8 years to craft a policy on a topic of such complexity heightens the likelihood of creating bias. Establishing a false standard of care and disenfranchising those not in support of its conclusions are inevitable consequences. Another Herculean request made of the commit- tee was to draft this policy to meet the needs, not only of all emergency physicians, but also neurologists. From a purely political perspective, this makes wonderful sense, and building bridges with other specialties is generally a good thing. Remarkably, emergency physicians and neurologists have usually not shared the same perspective on this issue. So, the fact that this committee was tasked with collaborating with the American Academy of Neurology may have foreshadowed its shortcomings before pen was put to paper. Perhaps, the salient question is: Why was the committee charged with such a task in the first place?