The New NICE Guidelines for Acute Stroke and TIA

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The new NICE Guidelines for Acute Stroke and TIA

Martin James Consultant Stroke Physician /Honorary Professor University of Exeter Medical School

South West Stroke Conference, September 2019 What is NICE saying about stroke?

 Mechanical thrombectomy (MT)  IV Thrombolysis (IVT)  Intracerebral haemorrhage  TIA

https://www.nice.org.uk/guidance/ng128 It’s all about reperfusion

Cerebral angiogram

Occluded50% dead;proximal 45% middle dependent; cerebral artery 5% independent Thrombectomy: the game changer

Stent retriever (Solitaire) What is NICE saying about thrombectomy?

 Mechanical thrombectomy (MT)  IV Thrombolysis (IVT)  Intracerebral haemorrhage  TIA

https://www.nice.org.uk/guidance/ng128 Who will benefit from thrombectomy?

Plus 1428 Minus 1428 918 2142 1836 2244 612 2142 (N=10,200) 306

612 1326 1632 3060 1224 2244 (N=10,200)

2000 4000 6000 8000 10,000

Berkhemer et al, NEJM Dec 2014 Time-to-reperfusion effect in the biggest trial

Median onset-to- 4 reperfusion 5h 40m

Fransen et al, JAMA, 2016 Imaging the culprit vessel in acute stroke Imaging the tissue at risk in acute stroke

• Dual-phase CT Angiography

Images courtesy of Dr Alex Mortimer Imaging the tissue at risk in acute stroke

• Perfusion CT

Images courtesy of Dr Alex Mortimer Advanced imaging selection using CT perfusion and RAPID automated analysis Albers et al DEFUSE-3 NEJM Jan 2018

UK: 9% of sites What is NICE saying about thrombolysis?

 Mechanical thrombectomy (MT)  IV Thrombolysis (IVT)  Intracerebral haemorrhage  TIA

www.strokeaudit.org.uk Time-to-reperfusion effects

• Data from Emberson et al, 2014 and Fransen et al, 2016 National thrombolysis rate 2013-19 Thrombolysis rate (All stroke) 40 35 30 25

% 20 15 12 12 11 11 12 12 12 11 11 12 11 12 12 11 12 12 12 10 11 11 11 11 5 0

Jul-Sep 2013 Jul-Sep 2014 Jul-Sep 2015 Apr-Jul 2016 Apr-Jul 2017 Jul-Sep 2018 Oct-DecJan-Mar 2013Apr-Jun 2014 2014Oct-DecJan-Mar 2014Apr-Jun 2015 2015Oct-DecJan-Mar 2015 2016Aug-Nov 2016 Aug-Nov 2017Apr-Jun 2018Oct-DecJan-Mar 2018 2019

Dec 2016-Mar 2017Dec 2017-Mar 2018

Source: Team-centred results for Key Indicator 3.1B National results The national average conceals a remarkable and inexplicable variation

Range 4 to 22% National door-to-needle time 2013-19

Door-to-needle

60 59 58 56 57 56 56 55 55 55 54 53 52 52 53 52 50 51 50 50 51 50 50

Minutes 20

Dec 2016-Mar 2017Dec 2017-Mar 2018

Source: Team-centred results for Key Indicator 3.5A National results What are your chances of being treated within 1 hour? IV thrombolysisThrombolysis in therateClock (AllSouth stroke) start West to thrombolysis time

Gloucestershire Royal GloucestershireNational Royal National average Great Western Swindon Great Westernaverage Swindon North Bristol 11.9%North Bristol 51 min North Devon District North Devon District Royal Cornwall Royal Cornwall Royal Devon and Exeter Royal Devon and Exeter Royal United Bath Royal United Bath Salisbury District Salisbury District Musgrove Park Musgrove Park Torbay Torbay Univ Hospitals Bristol Univ Hospitals Bristol Derriford Derriford Weston General Weston General Yeovil District Yeovil District

0 10 % 20all stroke30 400 50 60 Hours1 70 80 902 100 3 4 % Hours Jan-Source:March SSNAP2019 Jan-Mar 2019 SouthPatient-centred West region results at team level for Key Indicator 3.1A National National Team Team IQR median South West SCN IQR Median

Source: SSNAP Jan-Mar 2019 Patient-centred results at team level for Key Indicator 3.5A South West SCN Where’s the harm in a little local variation?

Current population benefit from IVT at 2018 thrombolysis rates = 10.9 excellent outcomes per 1000 stroke admissions

Range 3 to 32 excellent outcomes Where’s the harm in a little local variation?

Potential population benefit from IVT at 20% thrombolysis rates = 18.9 excellent outcomes per 1000 stroke admissions Improving quality in a complex environment

Overall onset-to-needle times for thrombolysis (minutes)

200 184 186 180 163 170 160 145 150 140 120 100 80 58 56 Door-to-needle 60 54 52 40 50 52 Onset-to-door 20 0 Acute Intracerebral Haemorrhage

• >50% mortality rate little changed for 20 years • Most effective treatment: stroke unit care • Surely lowering BP acutely must help? When are we going to get any better at treating intracerebral haemorrhage? • Things that might reduce haematoma size or growth – Blood pressure control – Safer anticoagulants and antiplatelets – Research trials: • tranexamic acid; coagulation FXa; desmopressin • intralesional alteplase (MISTIE III) • intraventricular alteplase via EVD (CLEAR III, Lancet, Feb 2017) – ‘more studies needed’ • better basic care: ABCD-ICH Acute BP lowering in ICH

• Two apparently contradictory trials — INTERACT-2 (Anderson et al, NEJM 2013): 2839 patients (majority Chinese) within 6 hrs with mainly small, deep ICH; BP target <140 within 1 hr — ATACH-2 (Qureshi et al, NEJM 2016): 1000 patients within 4.5 hrs with small, deep ICH Target 110-139 within 2 hours

• Significant differences between the trials makes meta-analysis difficult Reconciling INTERACT2 and ATACH2

• Moullaali et al – individual patient metanalysis – ESOC Milan 2019 • 3829 patients, NIHSS 11, age 63 (UK: M74, F80) • Metanalysis suggests that BP lowering to SBP of 120-130 mmHg for the first 24 hours is likely to be helpful in improving functional outcomes at 90 days • Lancet Neurology, Sept 2019 What is NICE saying about haemorrhage?

 Mechanical thrombectomy (MT)  IV Thrombolysis (IVT)  Intracerebral haemorrhage  TIA

www.strokeaudit.org.uk What is NICE saying about acute stroke?

 Mechanical thrombectomy (MT)  IV Thrombolysis (IVT)  Intracerebral haemorrhage  TIA National % of patients admitted to a SU within 4 hours of hospital admission

Stroke unit within 4 hours 100

62 58 58 60 59 60 59 59 60 59 60 60 59 58 58 57 55 54 54 55 53

% 50

Dec 2016-Mar 2017Dec 2017-Mar 2018

Source: Team-centred results for Key Indicator 2.1B National results What are your chances of getting admitted to a stroke unit within 4 hours? 84%

22%

NHS Atlas of Variation 2015 What are your chances of getting admitted to a stroke unit within 4 hours?

Proportions of patients getting to a stroke unit within 4 hours by time of day and day of the week At least 90% of stay on a stroke unit 100

84 84 85 84 84 85 85 85 85 85 85 83 82 82 83 82 81 83 82 83 82 75

% 50

Dec 2016-Mar 2017Dec 2017-Mar 2018

Source: Patient-centred results for Key Indicator 2.3A National results

Team-centred performance in the SW

Domain 2 - Stroke Unit

Gloucestershire Royal Great Western Swindon North Bristol North Devon District Royal Cornwall Royal Devon and Exeter Royal United Bath Salisbury District Musgrove Park Torbay Univ Hospitals Bristol Derriford Weston General Yeovil District

0 20 40 60 80 100 StrokeDomain 2 Unit score domain score

National Team

Source: SSNAP Jan-Mar 2019 Patient-centred results at team level for Domain 2 Source: SSNAPSouth West Jan SCN-March 2019 Team-centred performance for South West SCN

Stroke Care ‘Out of Hours’ Differences in the processes of care for patients admitted in normal working hours and out of hours

More likely for patients More likely for patients arriving during office hours arriving outside office hours

Compliance with process measures for office hours and out of hours patients (adjusted odds ratios) Campbell et al. PLOS One, 2014 30 day mortality of patients admitted at weekends, by ratio of registered nurses per 10 beds on the weekend Hazard ratios adjusted for patient casemix, organisational characteristics, staffing and care quality Stroke: Still working on it…

Number of Routinely Admitting Teams Overall Performance Team Centred Data patients Combi D4 D10 SSNAP D1 D3 D7 D8 D9 Std TC KI Team Name Admit Disch CA AC ned KI D2 SU Spec D5 OT D6 PT Disch Level Scan Throm SALT MDT Disch Level Level Asst Proc Gloucestershire Royal 205 213 D A A D C D↓ B↑↑ B↑↑ C D E D↑ B B D Hospital Great Western Hospital 104 116 D B↓ B D A E↓ C D↑ D↓ E↓ C↑ B↑ B↑ C↑ D Swindon North Bristol Hospitals 217 214 B↑ A A B↑ A C↑ B B B↑ B↑↑ C↑ C↑ C A↑ B↑ North Devon District 92 88 C A B↓ C D D NA E A B D↑ B A A C Hospital Royal Cornwall Hospital 195 182 B↑ A A B↑ A C↑ C B A B↑↑ B B↑ C C↓ B Royal Devon and Exeter 207 218 A A A A B↓ B D↓↓ B A A B B A↑ B A Hospital Royal United Hospital 169 173 B A B↓ B B C D↓↓ B A↑↑ C C↑ B B A B Bath Salisbury District Hospital 94 102 B A A B B↓ C D B B B E A↑ A B↑ B Musgrove Park Hospital 180 183 C A A↑ C↓ A D↓ D↓ D↓ C↓ B↓ E↓ C↓ B B C↓ Torbay Hospital 161 162 C↓ A A C↓ B↓ D↓ D↓ D A C↓ E B↑ B A C↓ University Hospitals 105 116 D↓ A B D↓ A↑ C C↑ D↓ C↓ D↓ C D↓ C↓ C↓ D↓ Bristol Inpatient Team Derriford Hospital 204 216 B A A B A D B↑ B↓ C B C E B B↓ C↓ Weston General Hospital 46 50 D C A D C E↓↓ D↓↓ C↑ A↑↑ B↑↑ D↑ E↓↓ B↓ C D Yeovil District Hospital 125 122 C↓ A A C↓ B↓ D↓ C↓↓ D A A C D↓ D A↑ C↓ What do people with acute stroke need?

Three things that will reduce death and disability: Better, quicker access to reperfusion therapies Better, quicker access to specialist expertise 24/7 access to high quality stroke services Better survival, less disability

www.england.nhs.uk What is NICE saying about TIA?

 Mechanical thrombectomy (MT)  IV Thrombolysis (IVT)  Intracerebral haemorrhage  TIA Key messages in acute stroke & TIA

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