Lest we forget: the other 97%


  • Conflict of interest: none declared.

Correspondence: Nitin K. Sethi, New York-Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68thStreet, New York, NY 10065, USA.

E-mail: sethinitinmd@hotmail.com

The advent of recombinant tissue plasminogen activator (r-tPA) therapy revolutionized the treatment of stroke for the lucky few who reach the hospital in time. Thrombolytic therapy has changed the treatment of ischemic stroke from a ritualistic to an active aggressive one. About 15 years ago, the National Institute of Neurological Disorders and Stroke (NINDS) trials involving tPA were performed [1] making thrombolytic therapy the standard of care for acute ischemic stroke patients presenting to the hospital within 3 h and, more recently, up to 4.5 h of symptom onset [2]. Time is brain and thus billions of dollars have been invested to help increase tPA usage. However, therapeutic uptake has been modest with only about 3% of acute ischemic stroke patients in developed and 1% in developing countries able to derive the benefit of r-tPA. What happens to the other unfortunate 97% to 99%? A visit to the major stroke conferences makes one ponder whether this other 97% is getting ignored. Conference time is primarily devoted to studies attempting to increase the therapeutic window and therapeutic uptake of thrombolytic therapy, emerging mechanical devices, and interventional procedures. Minimal conference time is devoted to the acute stroke patient who cannot derive the benefit of this wonder drug on account of been excluded due to some reason with arrival outside the 4.5 h window being the most commonly cited reason [3]. Core issues of poor compliance rate with antiplatelet and anticoagulant therapy, urinary tract, and respiratory infections which increase morbidity and mortality are rarely the ‘hot’ topics. Modification of stroke risk factors and timely placement of feeding and tracheostomy tubes is largely neglected. The goal of medicine should always remain doing the greatest good for the greatest number of people. The hype associated with tPA is not unjustified but the pendulum has swung to the other extreme. In a resource-limited country such as India, this approach seems hard to justify. We may or may not be able to improve tPA utilization rates further. We can, however, certainly improve stroke outcomes in the vast majority of patients by aggressively addressing the previously mentioned factors. So for this other 97%, the time has come to stand up and be heard.