Management of Acute Ischemic Stroke: A Review of Pertinent Guideline Updates

Carley E. DeVee, PharmD, BCPS; Ryan J. Sangiovanni, PharmD


US Pharmacist. 2019;44(2):HS2-HS5. 

In This Article

Thrombolytic Therapy

Recommendations regarding thrombolytic therapy with IV alteplase have largely remained unchanged in recent years.[3] Recommendations based on three randomized, controlled trials have expanded treatment with IV alteplase to otherwise eligible patients with "mild but disabling stroke." This was defined using the National Institutes of Health Stroke Scale, and most patients in these trials had a score between 0 and 5. Furthermore, guideline recommendations now state that it is at the discretion of the physician to use IV alteplase regardless of stroke score if the clinical benefit is believed to be higher than the risk.[4–6]

The new guidelines have also clarified that IV alteplase should not be administered to patients who have received treatment doses of low-molecular-weight heparin products within the previous 24 hours, whereas it has been previously implied that both prophylactic and treatment doses were contraindicated.[7] The new guidelines specify that IV alteplase should be administered to patients receiving antiplatelet monotherapy and dual antiplatelet therapy (DAPT), although administration with DAPT has a lower quality of evidence. The guidelines explain that mechanical thrombectomy should not be delayed in order to assess a patient's response to IV alteplase.[2]

There is significant expansion in the guidelines in highlighting the importance of establishing quality, time-effective hospital policies and procedures in stroke management. These recommendations emphasize the importance of allowing brain-imaging studies to be conducted promptly (within 20 minutes of arrival in the emergency department) and prompt administration of IV alteplase, if indicated (newly recommended metric of door-to-needle time of 60 minutes in 50% of stroke patients).[2] While the guidelines do not call upon pharmacists explicitly to aid in achieving these, they do suggest creating a "multidisciplinary quality improvement committee" to assess quality assurance measurements and metrics.[2] Some institutions have taken this a step further and proven that when made part of the interdisciplinary team, pharmacists were able to decrease door-to-needle time by 23.5 minutes.[8]