Post-acute care and secondary prevention after ischaemic strokeBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2083 (Published 08 April 2011) Cite this as: BMJ 2011;342:d2083
All rapid responses
Descriptional studies considering sampling and sizing in
cerebrovascular disease may be related to applicable stroke outcomes after-thrombolysis and intra-thrombolysis, considering methodology employed.
Thus, descriptional figures in NHS and Stroke Registry applications may
be related to recent studies:
Gunarathne A et al (2008) and risk
factors associated to thrombolysis :
-Secular trends in the cardiovascualr risk profile and mortality of stroke
admissions in an inner city , multiethnic population in the UK (1997-2005). J Hum Hypertens 2008 ; 22: 18-23.
-Increased 5-year mortality in the migrant South Asian stroke patients
with DM in the UK. The West Birmingham Stroke Project . Int J Clin Practice
2008 ; 62: 197-201.
-Derby CA. Trends in validated cases of fatal and non-fatal stroke, stroke
classification and risk factors in southeastern New England, 1980 to
1991. Data from the Pawtucket Heart Health Program. Stroke 2000 ; 31: 875-
Valuable results may be considered compared with classical studies:
Caro J et al. Management patterns and costs of acute ischemic stroke-An
international study. Stroke 2000 ; 31: 582
Competing interests: No competing interests
I am not suggesting that the towel should be thrown in on trying to
increase the numbers being thrombolysed. Thrombolysis rates are important
as the treatment was promoted - and continues to be promoted - on the
basis that many thousands could receive it and many millions of pounds
would be saved. Both claims have turned out to be less than accurate and
Martin Ferry may have noticed that the NAO dropped its 2005 claim from its
2010 report that there would be 1500 returned to independence and a 16
million pound saving made as a result of 9% (9,900) of stroke patients
Being open, transparent and realistic about a thrombolysis rate of
around 5 - 6% for the population would help politicians and the public
realise that much has been achieved. The point is that - given the
evidence around rehabilitation effects - time, effort, energy and money
may have been better spent for the majority of stroke patients who never,
ever would have been eligible for treatment.
Has there been a fair and just use of resources focusing on the needs
of a few stroke patients to the detriment of the majority?
Competing interests: No competing interests
Implementation of new, time critical treatment is challenging. Low
rates of thrombolysis for myocardial infarction were identified and
criticised several years after its benefit was established(1), and
prolonged effort was required to increase its use. Relative to myocardial
infarction thrombolysis for stroke demands more complex investigation and
treatment within a tighter time window. Despite this, significant
proportions of patients are treated at several UK centres, across Europe
and in the USA.
Dr Dudley's extensive correspondence(2-12) seems to focus on whether
or not an arbitrary target is being hit. In simple, practical terms what
is Dr Dudley suggesting should happen next? Should UK stroke doctors throw
in the towel and focus on rehabilitation strategies? I'd suggest that
rather than engage in lengthy debates over validity of thrombolysis
treatment rate estimates, their time would be better spent redesigning
their services to treat more patients.
1. Thrombolytic Therapy of Acute Myocardial Infarction: Keeping the
Unfulfilled Promises. Doorey AJ et al. JAMA. 1992;268:3108-31141.
2. Why does the BMJ promote the 10% stroke thrombolysis fallacy?
Nigel Dudley BMJ (Published 15 April 2011)
3. Stroke costs and thrombolysis rates: beliefs, aspirations and
delusions Nigel Dudley BMJ (Published 6 April 2011)
4. Stroke thrombolysis rates: hospital rate v population rate - which
provides a better measure for comparisons and eliminating postcode
prescribing? Nigel Dudley BMJ (Published 26 February 2011)
5. England's stroke FAST campaign has been evaluated: Health Minister
appears to have inadvertently misled Parliament on thrombolysis effects
and ROMI Nigel Dudley BMJ (Published 14 February 2011)
6. Incomplete response and SITS register limitations for outcome
studies Nigel Dudley BMJ (Published 21 January 2011)
7. The source of 15% thrombolysis estimate? Nigel Dudley BMJ
(Published 26 October 2010)
8. Does the Royal College of Physicians lead the way on wishful
thinking in stroke? Nigel Dudley BMJ (Published 30 September 2010)
9. A double whammy for stroke patients: was the NAO's 2005 claim of a
?16 million saving from thrombolysis a mistake? Nigel Dudley BMJ
(Published 25 May 2010)
10. More irrational optimism: 60.5% thrombolysis rate assumption in
economic model driving NHS London stroke services redesign Nigel Dudley
BMJ (Published 29 April 2009)
11. Irrational optimism: why is RCP stroke audit report's 15%
thrombolysis rate statistic 50% higher than the figure stated in the
August 2008 Phase 1 organisational report? Nigel Dudley BMJ (Published 27
12. Re: Stroke thrombolysis can reach 10% - and beyond. Nigel Dudley
BMJ (Published 21 April 2011)
Competing interests: No competing interests
I thank Dr McArthur and her colleagues for choosing to engage in a
debate about their 10% thrombolysis claims. I share the view that
thrombolysis is an evidence based treatment that is cost effective and
agree that stroke centres can achieve thrombolysis rates far in excess of
10%. Glasgow's own two stroke centres could have been used to illustrate
that to be true as - according to Scottish audit data - the Southern
General Hospital thrombolysed 109 of 601 (18.1%) stroke admissions in 2009
and the Western Infirmary Glasgow achieved a rate of 19.7% (79 of 401
When I refer to a thrombolysis rate of 10% I am referring to 10% of
the total stroke population (11,000 of 110,000 stroke patients in England,
1,500 of 15,000 stroke patients in Scotland). Whether I am being unduly
pessimistic or Dr McArthur and colleagues are being unduly optimistic
remains to be seen. However, given the facts that only 3,284 of that
11,000 in England and 411 of 1,500 in Scotland were thrombolysed in 2009
after years of sustained effort and significant investment in hyper-acute
service developments, I would consider my opinion to be realistic rather
than "unduly pessimistic". Would Dr McArthur or her more experienced
colleagues care to predict when such numbers will be achieved each year
based on their reading of the evidence? It would be helpful for the health
departments in England and Scotland to be more open and transparent and
publish graphs showing numbers treated each quarter so that politicians
and the public can see for themselves the progress towards the 10%
Dr McArthur and colleagues' response seems to suggest that the 10%
figure in fact refers to a stroke unit based rate not a population based
rate. However, it is clear that such units take selected patients from a
much wider population of stroke patients admitted to hospital in a
particular area. For example, in Glasgow in 2009 there were also 201
stroke admissions to Stobhill Hospital and 411 to the Glasgow Royal
Infirmary and neither of those two locations had on-site thrombolysis.
Therefore in Glasgow in 2009 there were 188 of a total of 1,614 stroke
admissions treated with thrombolysis, giving a hospital rate of 11.6% for
the Glasgow area. The 1,614 admissions do not represent the total number
of strokes in the Glasgow area as not all patients are admitted to
hospital. The local Glasgow population thrombolysis rate is likely to be
in single figures given that in Scotland only around 8,000 of the total
15,000 stroke patients are admitted.
The detail from England's 2007 National Stroke Strategy impact
assessment shows that the hyper-acute end of stroke - although
economically sound - has the least to offer in terms of overall economic
benefits to a wider stroke population (see table). There are many
effective rehabilitation strategies - for example, early supported
discharge - that have been largely ignored by commissioners and
politicians in recent years that have not had the time or resources made
available for development. That opinion is based on the evidence and
findings in the 2010 National Audit Office stroke progress report and the
sequential audit reports from the Royal College of Physicians.
When it comes to claims about a 10% thrombolysis rate and beyond
being achievable, it is necessary to spell out if the 10% rate applies to
a total stroke population, to the number of stroke patients admitted to
all hospitals in an area or to an individual stroke unit that offers
thrombolysis. It does make a difference in terms of the total numbers
likely to be treated and the savings that will flow from the small number
returned to independence.
 Department of Health. Impact Assessment: National Stroke
Strategy. December 2007.
Table. Outcome and financial impacts with December 2007 National Stroke Strategy interventions: brain imaging and thrombolysis; Stroke units; Early Supported Discharge (ESD); Community based stroke rehabilitation.
# - QALY gained per improved outcome and cost per QALY taken from page 42 of the Department of Health’s December 2007 Final Impact Assessment that accompanied the National Stroke Strategy (NSS).
* - Figures for the outcomes with interventions, costs, and savings taken from the “Base Case” columns of Tables 1, 2, 6 and 7 on pages 13 to 15 of the Department of Health’s December 2007 Final Impact Assessment that accompanied the NSS.
¶ Total stroke strategy net benefit of £502 million taken from the “Base Case” Table 8 on page 15 of the Department of Health’s December 2007 Final Impact Assessment that accompanied the NSS. The totals of the four interventions do not add up to 100% as benefits are gained from other elements of the NSS.
Competing interests: Peer reviewed BMJ stroke articles
We thank Dr Dudley for his interest in our two articles on acute
stroke treatment (1,2). The evidence base and practice of stroke medicine
is constantly evolving and we welcome all the learned debate that our
article has generated in the online "rapid responses" section of the
Dr Dudley states that a figure of 10% eligibility for thrombolysis
does not reflect current rates of thrombolytic usage and that by
implication achieving this rate of intervention is unfeasible. We accept
that the former statement is true, at present many UK centres offering
acute intervention are not achieving a 10% thrombolysis rate. However,
his latter statement is opinion and may be unduly pessimistic.
The figure of 10% we quote is taken from a recent editorial co-
authored by stroke researchers from various UK centres (3). We recognise
that provision of thrombolysis will vary with geographic, demographic and
infrastructural factors (4) and provided a caveat to that effect in our
article. Registry data exploring differences in treatment provision have
been explored between the UK and European centres that are known to
achieve rates of thrombolysis in excess of our own. Infrastructural
deficiencies are highlighted, particularly pertaining to the frequency of
treatment out of office hours (5). Research exploring different models
to improve delivery of thrombolytic therapy with a twenty four hour
service and in areas remote from stroke centres is ongoing, but learning
from the experience of other countries would suggest that improved rates
of intervention can be achieved (6). The current licence, with
restrictions based on time and clinical features, further limits use of
intravenous Alteplase. However with increasing experience and supported
by clinical trial evidence (7) and robust observational data (8), many
centres are increasing the proportion of patients they will consider for
thrombolysis. We await future randomised data from the third
international stroke trial (IST3) (9) due later this year which should
offer clarity for the extended use of thrombolysis beyond current license,
potentially offering scope for yet more patients to access treatment.
If achieving the figure of 10% requires ongoing hard work within the
stroke community and beyond, we make no apologies for this - such an
attitude is commensurate with the modern aggressive and optimistic
paradigm of stroke care we wished to emphasise in the article. Our
figures may be aspirational but they are not unrealistic, centres in other
European countries achieve thrombolysis rates far in excess of 10% (6).
Although we may disagree on the details, most of the stroke community
would concur that improving access to, and availability of, thrombolysis
is evidence based and economically sound (10). Data suggests that 37% of
patients present to emergency services well within the current
thrombolysis window (11) and we must strive to ensure that all appropriate
patients have access to the only acute treatment proven to prevent and
reduce disability. We acknowledge that increasing UK rates of
thrombolysis requires more than just enthusiastic clinicians. Thus we are
encouraged by recent public health campaigns to increase awareness of
acute stroke as a medical emergency and we welcome changes in the delivery
of stroke care across the UK to increase emphasis on "hyper-acute" care.
The organisational challenges posed by thrombolysis in acute stroke must
be viewed as a target, rather than an excuse to abandon the only effective
acute strategy yet developed.
1) McArthur KS, Quinn TJ, Dawson J, Walters MR. Diagnosis and
management of transient ischaemic attack and ischaemic stroke in the acute
phase. BMJ 2011;342:d1938
2) McArthur KS, Quinn TJ, Higgins P, Langhorne P. Post-acute care and
secondary prevention after ischaemic stroke.BMJ. 2011;342:d2083.
3) Langhorne, P. Sandercock P. Prasad, K. Evidence-based practice for
stroke. Lancet Neurology, 2009; Vol 8: 307-309
4) Kwan J, Hand P, Sandercock P. A systematic review of barriers to
delivery of thrombolysis for acute stroke.Age Ageing.2004; 33: 116-121.
5) Lees KR, Ford GA, Muir KW, Ahmed N, Dyker AG, Atula S, Kalra L,
Warburton EA, Baron JC, Jenkinson DF, Wahlgren NG and MR Walters for the
SITS-UK Group. Thrombolytic therapy for acute stroke in the United
Kingdom: experience from the safe implementation of thrombolysis in stroke
(SITS) register. Q J Med 2008; 101:863-869
6) Wahlgren N, Ahmed N, D?valos A, Ford GA, Grond M, Hacke W,
Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L,
Toni D, VanhoorenGfor the SITS-MOST investigators. Thrombolysis with
alteplase for acute ischaemic stroke in the Safe Implementation of
Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational
study. Lancet.2007; 369:275-282.
7 )Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, et
al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic
stroke. N Engl J Med2008;359:1317-29.
8) Mishra NK, Ahmed N, Andersen G, Egido JA, Lindsberg PJ, Ringleb
PA, et al, for the VISTA and SITS collaborators. Thrombolysis in very
elderly people: controlled comparison of SITS International Stroke
Thrombolysis Registry and Virtual International Stroke Trials Archive.
9) Whitely W, Lindley R, Wardlaw J, Sandercock P on behalf of the IST
-3 Collaborative Group. Third International Stroke Trial. International
Journal of Stroke. 2006; 1(3): 172-176
10) Quinn TJ, Dawson J. Acute 'strokenomics': efficacy and economic
analyses of alteplase for acute ischemic stroke. Expert Review of
Pharmacoeconomics& Outcomes Research. 2009; 9(6):513-22
11) Harraf F, Sarhma AK, Brown MM, Lees KR, Vass RI, Kalra L for the
Acute Stroke Intervention Study Group. A multicentre observational study
of presentation and early assessment of acute stroke. BMJ. 2002; 325
Competing interests: No competing interests
The BMJ's two clinical reviews of stroke indicate a thrombolysis rate
of 10% that equates in a year to 11,000 of England's 110,000 stroke
population and 1,500 of Scotland's estimated 15,000 stroke patients being
treated.  The 2009 stroke audit in Scotland noted that just 411 of the
15,000 stroke patients were thrombolysed giving a population rate of just
2.7%. The 2009 stroke audit for England, Wales and Northern Ireland
noted 3,284 being thrombolysed - the vast majority of whom were in England
- giving a rate of around 3% in England.
Few stroke experts would disagree with a view that Glasgow - the city
of the authors for the BMJ's papers with a population of some 1 million
people - has one of the best thrombolysis services in the United Kingdom
if not the world. The Western Infirmary Glasgow (that commenced
thrombolysis in 1997) managed to treat 79 people and the Southern General
Hospital (service commenced 1996) thrombolysed 109 people in 2009, making
a total of 188 for the city. The latest BMJ paper indicates in table 1
the projected effects of various interventions on a population of 1
million - a Glasgow sized population - that produces 2500 stroke patients
each year. At the real life Glasgow thrombolysis rate, 188 of 2500 would
be treated, giving a population thrombolysis rate of 7.5%.
When even the best services that have been operating for well over 10
years are not delivering thrombolysis at a rate of 10% to the local
population, why does the BMJ persist in ignoring the evidence of real life
in favour of the hope and aspirations of stroke experts? By what date do
the stroke experts and the BMJ predict that politicians and the public
will see 11,000 stroke patients in England and 1,500 in Scotland being
treated with thrombolysis as the return for their high investment in
hyperacute services over recent years?
 Scottish Stroke Care Audit. 2010 National Report. Stroke Services
in Scottish Hospitals. Data relating to 2005 - 2009.
Competing interests: Peer reviewed the two BMJ stroke articles