Compendium June 2010 : P 322

Letter to the Editors A Response to “Dental Implications of Acute Stroke Therapy and Anticoagulation for Stroke Prevention” I read with great interest the article entitled “Dental Impli - cations of Acute Stroke Therapy and Anticoagulation for Stroke Prevention” by Picard et al in the April 2010 issue of Compendium. The article provided valuable information to oral healthcare providers as it relates to acute ischemic stroke. The authors state that current management for treatment of acute ischemic stroke includes the use of recombinant tissue plasminogen activator (rt-PA) within the first 3 hours of the stroke to disintegrate clots. When indicated for use, this agent has demonstrated significant efficacy in reducing per- manent disability in acute ischemic stroke.1 However, the re commendations for the time frame have changed re cently. According to the European Cooperative Acute Stroke Study (ECASS) III trial, rt-PA administration in 3 to 4.5 hours of symptom onset of acute ischemic stroke significantly im - proved clinical outcomes.2 In light of the ECASS III study, the American Heart Association and American Stroke Asso - ciation recently published an advisory statement recom- mending administration of rt-PA to eligible pa tients in the 3- to 4.5-hour window (Class I recommendation, Level of Evidence B).3 However, exclusion criteria for this current recommendation include an age older than 80 years, the use of oral anticoagulants with an international normalized ratio (INR) of ≤ 1.7, a baseline National Institutes of Health Stroke Scale Score of > 25, or both a history of stroke and diabetes mellitus (Class IIB recommendation, Level of Evi - dence C).3 The advisory recommends that for the 3- to 4.5-hour window, all patients using oral anticoagulants are excluded regardless of their INRs.3 322 Compendium This updated information is critical in the management of acute ischemic stroke because it provides an increased opportunity for oral healthcare providers to reduce the mor - bidity and mortality associated with this condition. Sincerely, Eric T. Stoopler, DMD Assistant Professor of Oral Medicine Director, Oral Medicine Residency Program University of Pennsylvania School of Dental Medicine Philadelphia, Pennsylvania REFERENCES 1. Kwiatkowski TG, Libman RB, Frankel M, et al. Effects of tissue plasminogen activator for acute ischemic stroke at one year. Na - tional Institute of Neurological Disorders and Stroke Recombi - nant Tissue Plasminogen Activator Stroke Study Group. N Engl J Med. 1999;340(23):1781-1787 2. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alte - plase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329. 3. Del Zoppo GJ, Saver JL, Jauch EC, et al; American Heart Asso ciation Stroke Council. Expansion of the time window for treat ment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009; 40(8):2945-2948. June 2010—Volume 31, Number 5

Lettert To The Editors

A Response to “Dental Implications of Acute Stroke Therapy and Anticoagulation for Stroke Prevention”Read with great interest the article entitled gDental Impli - cations of Acute Stroke Therapy and Anticoagulation for Stroke Preventionh by Picard et al in the April 2010 issue of Compendium. The article provided valuable information to oral healthcare providers as it relates to acute ischemic stroke. The authors state that current management for treatment of acute ischemic stroke includes the use of recombinant tissue plasminogen activator (rt-PA) within the first 3 hours of the stroke to disintegrate clots. When indicated for use, this agent has demonstrated significant efficacy in reducing permanent disability in acute ischemic stroke.1 However, the re commendations for the time frame have changed re cently. According to the European Cooperative Acute Stroke Study (ECASS) III trial, rt-PA administration in 3 to 4.5 hours of symptom onset of acute ischemic stroke significantly I'm - proved clinical outcomes.2 In light of the ECASS III study, the American Heart Association and American Stroke Asso - ciation recently published an advisory statement recommending administration of rt-PA to eligible pa tients in the 3- to 4.5-hour window (Class I recommendation, Level of Evidence B).3 However, exclusion criteria for this current recommendation include an age older than 80 years, the use of oral anticoagulants with an international normalized ratio (INR) of . 1.7, a baseline National Institutes of Health Stroke Scale Score of > 25, or both a history of stroke and diabetes mellitus (Class IIB recommendation, Level of Evi - dence C).3 The advisory recommends that for the 3- to 4. 5-hour window, all patients using oral anticoagulants are excluded regardless of their INRs.3 This updated information is critical in the management of acute ischemic stroke because it provides an increased opportunity for oral healthcare providers to reduce the mor - bidity and mortality associated with this condition.Sincerely, Eric T. Stoopler, DMD Assistant Professor of Oral Medicine Director, Oral Medicine Residency Program University of Pennsylvania School of Dental Medicine Philadelphia, Pennsylvania.

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