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BMJ 2012; 344 doi: (Published 29 May 2012) Cite this as: BMJ 2012;344:e3731

Thrombolysis for older adults with acute ischaemic stroke

Two new analyses suggest the benefits of thrombolysis for acute stroke extend to adults aged >80 years. A large trial and an updated meta-analysis also show that intravenous recombinant tissue plasminogen activator (rt-PA) can work beyond the recommended three hour window between symptoms and treatment, although the precise time limits for treatment aren’t yet clear.

The new trial included 3035 adults with acute ischaemic stroke, who were treated up to six hours after symptom onset. More than half were over 80 years old. While results were mixed, rt-PA did seem to reduce the level of disability over six months in secondary analyses (a significant shift in Oxford handicap scores, adjusted odds ratio 1.27 (95% CI 1.10 to 1.47)).

When the new data were pooled with data from nine previous trials, adults treated with rt-PA were significantly more likely to be alive and independent at the end of follow-up than controls given placebo or usual care (1611/3483 (46.3%) v 1434/3404 (42.1%), odds ratio 1.17 (1.06 to 1.29)). The benefits looked similar for people older and younger than 80 years. As did the risks: rt-PA was associated with a significant excess of intracranial bleeds (7.7% v 1.8%, odds ratio 3.72 (2.98 to 4.64)) and early deaths (8.9% v 6.4%, 1.44 (1.18 to 1.76)). But later benefits outstripped the early hazard and, by the end of follow-up, adults of all ages did better after rt-PA.

As expected, rt-PA worked best when given within three hours of stroke onset, and timing remains critical, says a linked editorial (doi:10.1016/S0140-6736(12)60822-8).

Long term aspirin helps prevent recurrent venous thromboembolism

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People who have one unprovoked episode of venous thromboembolism are at risk of having another once they stop taking oral anticoagulants such as warfarin. …

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