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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Estimated gain in life expectancy. A simple tool to select optimal reperfusion treatment in individual patients with
H Boersma1, M J van der Vlugt, A E Arnold
1Thoraxcenter, Erasmus University, The Netherlands.
Insights
A new model predicts reperfusion therapy benefits for acute myocardial infarction patients, guiding treatment decisions based on potential life expectancy gains. This helps allocate resources effectively, ensuring patients receive the most beneficial therapy despite cost limitations.
Area of Science:
- Cardiology
- Health Economics
- Medical Decision Making
Background:
- Acute myocardial infarction (AMI) requires timely reperfusion therapy, with options like streptokinase, accelerated alteplase, and direct angioplasty.
- These therapies vary in complexity and cost, necessitating careful resource allocation in clinical practice.
- Physician choices are often constrained by budget limitations, impacting the delivery of optimal patient care.
Purpose of the Study:
- To develop a predictive model for the expected clinical benefit of reperfusion therapy in AMI patients.
- To guide decision-making in resource-limited settings by quantifying potential gains in life expectancy.
- To ensure consistent and optimal therapy allocation based on individual patient benefit.
Main Methods:
- A model was developed to predict the gain in life expectancy following reperfusion therapy for AMI.
- The model incorporates factors such as age, prior infarction history, estimated infarct size, treatment delay, and intracranial bleeding risk.
- Expected benefits were tabulated, and decision thresholds were established for different therapies (no therapy, streptokinase, accelerated alteplase, direct angioplasty).
Main Results:
- Clinical benefit varied significantly, from negligible gains in late-treated small infarcts to over 2 years in large infarcts treated within 3 hours.
- The model guided resource allocation, with proposed thresholds: <1 month gain (no therapy), 1-4 months (streptokinase), >=5 months (alteplase), >=12 months (angioplasty).
- This approach aimed to treat ~80% with thrombolytics and 10% with angioplasty, reserving no therapy for late-presenting small infarcts.
Conclusions:
- The developed model provides a consistent framework for optimizing reperfusion therapy decisions in AMI, even with budget constraints.
- It allows for the allocation of the most effective therapy to patients predicted to gain the most life expectancy.
- While thresholds are center-specific, the model ensures rational and evidence-based treatment choices for evolving myocardial infarction.
Abstract:
Currently several modes of reperfusion therapy for acute myocardial infarction are available. Streptokinase, accelerated alteplase and direct angioplasty are the most frequently used. These options are increasingly effective, but are also increasingly complex and costly. Since, unfortunately, physicians are often restricted by budget limitations, choices must be made in clinical practice to provide optimal therapy to individual patients. In order to guide such decision making, we developed a model to predict the expected benefit of therapy in terms of gain in life expectancy. Patients' life expectancy will decrease after infarction. Part of this loss can be prevented by early reperfusion therapy. The clinical benefit of therapy ranges from negligible gain in patients with small infarcts treated relatively late to an expected gain of more than 2 years in patients with extensive infarction treated within 3 h of onset of symptoms. The expected benefits are presented in a set of tables and depend on age, previous infarction, estimated infarct size, treatment delay and intracranial bleeding risk. With the help of these table, resources will be allocated in such a manner that patients who will benefit the most will receive the most effective therapy. Patients with similar expected treatment benefit will be offered the same mode of therapy. Future life years were discounted at 5% per year. The arbitrary thresholds currently applied for decision making at the Thoraxcenter are: no reperfusion therapy when the estimated gain in discounted life expectancy was < 1 month, streptokinase for 1-4 months and accelerated alteplase for a gain > or = 5 months. Direct angioplasty is recommended in patients with an estimated gain > or = 12 months, and in patients with an increased risk of intracranial bleeding. In this way, approximately 80% of our patients will be treated with thrombolytics (40% streptokinase and 40% accelerated alteplase), while in 10% direct angioplasty will be initiated. Patients with small infarcts presenting late will not receive reperfusion therapy. These threshold values have been chosen arbitrarily, and different thresholds may be selected in other centres. However, the developed model would guarantee that treatment decisions are made in a consistent manner, to provide optimal therapy for patients with evolving myocardial infarction, in spite of limited resources.
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