A Second Look: AHA/ASA Retracts Sections of 2018 Stroke Guidelines
In a move that surprised much of medical community, the American Heart Association/American Stroke Association (AHA/ASA) unexpectedly retracted sections of its 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. The guidelines were originally released at the 2018 International Stroke Conference in Los Angeles in January.
The sections were withdrawn following “recent feedback received from the clinical stroke community,” said an April 18 correction notice posted on the website of the journal Stroke. “After review, a revised guideline, with consideration given to the clarifications, modifications, and/or updates of the sections noted above, will be posted over the coming weeks.”
Published in the March 2018 edition of Stroke, these regularly updated guidelines are used by EMS, hospitals, and cardiac care physicians to plan the treatment of stroke patients. While not law, they reflect current best practices and evidence-based wisdom regarding all aspects of caring for AIS patients. With certain sections (detailed below) having been pulled pending further clinical peer review, those who rely on these guidelines have been advised to refer to the AHA/ASA’s previous document on acute ischemic stroke, published in 2013.
Given that this stroke management document is the AHA/ASA’s “flagship guidelines that outline everything from prehospital care through posthospital recommendations,” says Peter Panagos, MD, incoming chair of the AHA’s Stroke Council, having sections of it suddenly retracted shortly after publication did not imbue the medical community with a sense of confidence. But according to the AHA/ASA correction posting, the decision to retract these sections is in line with the association’s commitment to rigorously research and review treatment recommendations.
“Ensuring our scientific guidelines reflect the best, most comprehensive scientific analysis has always been, and remains, the association’s top priority,” said the AHA/ASA posting. “We appreciate the continuing commitment and dedication of our volunteer writing group, peer reviewers, and the scientific community at large, who share our devotion to the integrity and quality of guideline development.”
What’s Been Retracted
The following sections the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke have been retracted. (The descriptions below are the quoted recommendations from the original document.)
- Section 1.3, EMS Systems, Recommendation #4—When several IV alteplase-capable hospital options exist within a defined geographic region, the benefit of bypassing the closest to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy, is uncertain. Further research is needed.
- Section 1.4, Hospital Stroke Capabilities, Recommendation #1—Certification of stroke centers by an independent external body, such as the Center for Improvement in Healthcare Quality, Det Norske Veritas, the Healthcare Facilities Accreditation Program, or the Joint Commission, or a state health department, is recommended. Additional medical centers should seek such certification.
- Section 1.6, Telemedicine, Recommendation #3—Because of the limited distribution and availability of neurological, neurosurgical, and radiological expertise, the use of telemedicine/telestroke resources and systems can be beneficial and should be supported by healthcare institutions, governments, payers, and vendors as one method to ensure adequate 24/7 coverage and care of acute stroke patients in a variety of settings.
- Section 2.2, Brain Imaging, Recommendation #11—Additional imaging beyond CT and CTA or MRI and magnetic resonance angiography (MRA), such as perfusion studies for selecting patients for mechanical thrombectomy in less than six hours, is not recommended.
- Section 3.2, Blood Pressure, Recommendation #3—Until additional data become available, in patients for whom intra-arterial therapy is planned and who have not received IV thrombolytic therapy, it is reasonable to maintain a blood pressure of 185/110 mmHg before the procedure.
- Section 4.3, Blood Pressure, Recommendation #2—In patients with blood pressure less than 220/120 mmHg who did not receive IV alteplase or EVT and do not have a comorbid condition requiring acute antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48–72 hours after an AIS is not effective to prevent death or dependency.
- Section 4.6, Dysphagia, Recommendation #1—Dysphagia screening before the patient begins eating, drinking, or receiving oral medications is reasonable to identify patients at increased risk for aspiration.
As well, all 11 subsections of Section 6.0, In-Hospital Institution of Secondary Prevention: Evaluation, have been retracted. Those retracted subsections are:
- 6.1. Brain Imaging
- 6.2. Vascular Imaging
- 6.3. Cardiac Evaluation
- 6.4. Glucose
- 6.5. Cholesterol
- 6.6. Other Tests for Secondary Prevention
- 6.7. Antithrombotic Treatment
- 6.8. Statins
- 6.9. Carotid Revascularization
- 6.10. Smoking Cessation Intervention
- 6.11. Stroke Education
According to Panagos, the release of the 2018 guidelines was timed to coincide with both the 2018 International Stroke Conference and the release of a key endovascular paper in the New England Journal of Medicine, DEFUSE 3.
Getting the 2018 guidelines written, edited, and reviewed for this deadline required “a lot of planets and stars lining up to get this comprehensive and complex document released by that time,” says Panagos. But a tight deadline wasn’t the only challenge: The guidelines’ editorial format was changed from a straight narrative form to one where “it would take a particular question and make a statement; identify the level of evidence and science behind it; and then in a very small block underneath that—with a limited number of words—succinctly summarize what the rationale was behind each recommendation,” Panagos says. “Visually, it was quite different than people had seen before. I think that caught some people off guard.”
A further factor that may have made some clinicians react was the “calculated decision” by the writing group not to make strong recommendations unless backed by solid evidence, rather than common practices. After all, “a lot of the things we do in life and medicine are based on routine and experience, but not necessarily based upon the highest level of evidence,” says Panagos. This led to the 2018 guidelines offering “lukewarm or less-than-strong recommendations for a lot of common practices in stroke care, which caught some people by surprise.”
Section 1.3, EMS Systems, Recommendation #4 was one example: “When several IV alteplase-capable hospital options exist within a defined geographic region, the benefit of bypassing the closest to bring the patient to one that offers a higher level of stroke care, including mechanical thrombectomy, is uncertain,” said the recommendation. This assertion upset those in the medical community who believe taking a patient to the highest level of stroke care, rather than the closest care available, is the best course of action, Panagos says.
Fierce Feedback, Quick Response
The comments received by the AHA/ASA were “voluminous and very passionate,” says Panagos. Faced with this storm, the AHA/ASA made the “unprecedented decision” to “reconvene our writing group, look at some of the questions and concerns in the stroke community, and see if there’s anything we need to do differently,” Panagos says. “Let’s pull back a few sections of the new guidelines, review the evidence and the wording of the recommendations, and see if we still believe strongly in these or if they would read better with some modifications.”
In retracting and reviewing these contested sections, the AHA/ASA isn’t abandoning the positions taken by its writing group. But since the association is volunteer-based and values the feedback of its members, it made sense to heed their concerns and take a second, hard look at these sections.
Meanwhile, “the rest of the recommendations remain in place,” says Panagos. With any luck, a revised, complete version of the 2018 guidelines will be released later this year.
What It Means for EMS
Unless your area has multiple hospitals with extended stroke capabilities, these retractions likely won’t have a big impact on your system. In the meantime, “there are still some very good EMS recommendations in the abridged 2018 guidelines,” Panagos says. “As always in the EMS community, I would also refer to your local medical directors group to review existing data and local resources to come up with a stroke management plan that works best within the strengths and weakness of your local or regional system.”
James Careless is a freelance writer and frequent contributor to EMS World.