Why was the study done?

IV tissue plasminogen activator (tPA) is a clot-busting medication that can be used to treat ischemic strokes. Ischemic strokes are caused by clots that block blood flow to the brain. tPA is infused into a patient's arm through an IV. It can dissolve a clot and restore blood flow to the part of the brain that had been cut off. The tricky part is that for the tPA to work, it must be given within 4.5 hours of stroke onset. When patients are given tPA, they have higher chances of getting better from their stroke.

But more than 20 years after the approval of tPA, and despite efforts to make people aware of its use, only about 3%–7% of stroke patients actually receive the drug in the United States. The rates of tPA use among older patients, women, minorities, and those living in rural areas are even lower.¹ Mendelson et al.² considered whether patients or their caregivers refusing tPA contributed to these lower rates of tPA use, particularly among black Americans.

How was the study done?

The research team looked back at patients who had acute strokes between January 2013 and June 2015 at 15 Chicago primary stroke centers. These primary stroke centers gave these data to the American Heart Association Get With the Guidelines Stroke registry.³ This registry was started in 2003 to establish best practices for stroke treatment, share information with other member hospitals, and measure their performance.

The patients included in the study came to the emergency department within 4.5 hours from when symptoms began. Some patients were given tPA, while others were not. The research team looked at when patient refusal was listed as the only reason why tPA was not given. They analyzed what factors could have influenced this decision to refuse tPA. These included race–ethnicity, health insurance status, how they arrived (e.g., via ambulance or not), and stroke severity. Patients who had medical reasons for not being given tPA were excluded from the study.

What were the results?

There were 13,662 patients whose records were reviewed for this study. Half of them were women and nearly half (47%) were black. A total of 7.5% of all the patients or their caregivers refused treatment with tPA. More black patients refused (10.6%) compared to patients of other races (4.8%). Those who were older and had prior strokes were also more likely to refuse tPA. Health insurance and stroke severity were also associated with refusing tPA. However, even after controlling for all of these factors, black patients or their caregivers were 2.5 times more likely to refuse tPA.

What does this mean?

This study shows that black patients or their caregivers were more likely to refuse tPA, a medication that can improve how patients recover after a stroke. As neurologists, we would like all patients who can take tPA to receive it and get better. Patients may refuse treatment because they do not know enough about it, because doctors did not fully explain the benefits, or owing to mistrust of doctors in general.

What can be done?

Neurologists can work with community-based organizations to identify cultural and community barriers to receiving tPA. They can develop educational material for different minority groups based on identified community barriers, and continue to invest in public education on acute stroke recognition and its treatments. In addition, there can be increased focus on improving physician communication, particularly among physicians who must explain tPA treatment to patients and get approval. For example, material outlining the benefits and risks of tPA can be provided to physicians so they can inform patients. Physicians could also use visual aids to show these benefits and risks. This is not the only area in neurology where there are racial differences in care.⁴ These differences should drive neurologists and community partners to address why the differences exist and what can be done about them.