The use of thrombolytics for acute ischemic stroke may be one of the most controversial topics in emergency medicine during the last several decades. This debate recurs in multiple forums including many previous pieces in ACEP Now.¹ The reason is understandable—thrombolytics in stroke is a high-risk, higher-reward treatment. If the potential for harm were absent, or if the benefit of thrombolytics was only marginal, there would be no controversy. Because both real risk and very real reward are at play, the debate persists.

However, like any topic—including the optimal medications for rapid sequence intubation or whether Pepsi is better than Coke—these discussions largely live in a stratosphere far above our daily clinical practice. In the setting of regular patient care, the debate is over. There continues to be consistent evidence favoring treatment. Professional organization guidelines universally support the use of thrombolytics, including the American Heart Association and ACEP.^2,3 Hospital policies and stroke protocols include thrombolytic administration for eligible patients as a rule. Systems of care have evolved to better support emergency physicians in overall stroke care and, specifically, decisions on giving thrombolytics. Because of the increased availability of neurology consultation, expansion of telestroke, and clear hospital protocol, emergency physicians are less alone in deciding when to give thrombolytics. Another argument is also there—emergency physicians don’t want to be sued; data consistently show that medical malpractice risk is much greater for undertreatment of stroke. When we care for eligible patients with ischemic stroke in the emergency department (ED), there is no debate: We administer thrombolytics when the opportunity presents.

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Acceptance of thrombolytics in stroke is exemplified in the results from a survey of EDs participating in ACEP’s Emergency Quality Network (E-QUAL) Stroke Collaborative. This learning network engages community EDs, regardless of setting or size, that are interested in improving stroke care. As part of the collaborative, we performed a capabilities assessment to understand the resources of participating sites. Last year’s assessment demonstrated widespread adoption of thrombolytics for stroke among emergency physicians (see Figure 1).

Diagnostic Efficiency

Moving past the debate of whether to administer thrombolytics enables us to engage in a new set of conversations related to stroke care in the ED.

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First, we are now operating in a paradigm in which the ED can provide tremendous diagnostic efficiency for acute stroke. Nearly all community EDs reported having access to CT angiography, thrombolytics, and even neurology (see Figure 2). Many (71 percent in our sample) even had access to perfusion imaging, whether through MRI or CT perfusion.

Today, the integrated stroke system of care is far advanced from when the initial research in this space was performed. We are equipped to rapidly identify eligible patients and, in most cases, have the ability to make specialist-supported treatment decisions. In fact, although they may not have an official stroke certification, data from E-QUAL showed that many U.S. hospitals are already well equipped to function as Acute Stroke Ready Hospitals. These sites have the necessary structure to receive patients with acute ischemic stroke, administer timely thrombolytics, and identify those who require transfer for thrombectomy or a higher level of care. In areas where stroke center certification does not provide a prehospital triage advantage, such as remote and rural settings, hospitals may not invest in these official designations. Nevertheless, these sites are increasingly demonstrating that they have the necessary structures to function as an Acute Stroke Ready Hospital with the right processes and resources in place.

Stroke Identification

Second, emergency physicians have a broad skillset and are particularly suited for identification of patients who will benefit from all types of treatments—from extracorporeal membrane oxygenation to lithotripsy. We combine data related to the patient’s profile, physical examination, onset of timing, and imaging results to form the complete clinical picture. Our role is no longer to decide whether thrombolytics work or not, but to identify and treat patients who will benefit. The latest research underscored that there is more nuance to treatment than a simple “yes” or “no” for thrombolytics, and that our skillset, along with our consultants, can help drive the best outcomes for our patients.⁴

For example, in the prehospital setting, we must consider how potential stroke is identified and which patients should be diverted to thrombectomy-capable and comprehensive stroke centers to ensure timely treatments, while avoiding overwhelming already-full tertiary care centers. In the ED, how do we create efficient and effective stroke protocols that include optimal imaging strategies, the selection of the best thrombolytic agent, and the management of wake-up strokes? And in stroke systems of care, how do we determine who to transfer, when to transfer, and how to transfer patients with stroke in a timely manner, particularly in the era of severe hospital crowding, significant ED boarding, and critical health care workforce shortages (EMS, nursing, techs, and board-certified emergency physicians)?

Like other practices, we will need learning networks like E-QUAL and other systems of care with well-developed protocols including engaging our consultants to support treatment decisions. As we recognize the growing strength of our systems for acute stroke care, we have the tools and resources to provide optimal care for our patients. It is now imperative to push the conversations in our specialty to the next level, ensuring high quality care delivery and the best outcomes for our patients.

The authors would like to acknowledge ACEP staff members Megan Sambell, Prateek Sharma, Sam Shahid, and Yale University statistician and E-QUAL data analyst Craig Rothenberg for their support and contributions to this work.

Dr. Zachrison is an associate professor of emergency medicine at Massachusetts General Hospital and Harvard Medical School and Chief of the Division of Health Services Research for Mass General Brigham Emergency Medicine.

Dr. Lo is the chief of emergency medicine at Sentara Norfolk General and professor at Eastern Virginia Medical School in Norfolk, Va. He is a partner with Emergency Physicians of Tidewater, a local private, democratic group, and chaired the ACEP clinical policy subcommittee on stroke thrombolytics.

Dr. Jauch is chair of the Department of Program Evaluation and Research at the University of North Carolina Health Sciences at MAHEC.

Dr. Venkatesh is professor and chair of emergency medicine at Yale School of Medicine and chief of emergency medicine at Yale New Haven Hospital.

References

1. Radecki RP. Is the tPA-for-stroke debate over? ACEP Now. 2018;37(6).
2. Power WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. [published correction appears in Stroke. 2019 Dec;50(12):e440-e441]. Stroke. 2019;50(12):e344-e418.
3. ACEP. Thrombolytics for the management of acute ischemic stroke. Accessed November 4, 2024.
4. Radecki RP. The latest research in neurologic emergencies. ACEP Now. 2024;43(9).