Fire It Up: Delayed tPA, Lipids and Cardiovascular Outcomes, Stroke Prevention, and Fournier’s Gangrene with SGLT2 Inhibitors


Michael Fralick and John Fralick, general internists in Toronto, are back on The Rounds Table and they are covering four articles in a rapid-fire style.  They discuss the use of tissue plasminogen activator (tPA) up to 9 hours after stroke onset, nonfasting versus fasting lipids and cardiovascular outcomes, the use of dabigatran for stroke prevention, and sodium-glucose cotransporter-2 (SGLT2) inhibitors and the risk of Fournier’s gangrene.

The gold standard for ischemic stroke is intravenous thrombolysis or tPA if patients present within four and a half hours of symptom onset.  After this, there are worse outcomes and risk of bleeding.  Perfusion imaging has allowed identification of areas of brain that may be salvageable.  John covers an article on thrombolysis guided by perfusion imaging up to nine hours after onset of stroke, compared to placebo, assessing outcomes including score on the modified Rankin scale and safety profile.

Guidelines have recommended routine testing of nonfasting lipid levels from comparisons done between nonfasting and fasting groups.  Mike discusses a post-hoc follow-up study from the ASCOT trial to assess whether nonfasting versus fasting lipids in the same population are associated with risk of subsequent cardiovascular events.

Cryptogenic stroke occurs in 20 to 30% of stroke cases.  These cases are believed to be embolic, but etiology is not identified.  Current guidelines recommend secondary stroke prevention with ASA, ASA and dipyridamole, or ASA and clopidogrel.  John informs listeners on an article assessing dabigatran compared to ASA for stroke prevention in patients with cryptogenic stroke.

Fournier’s gangrene is described as an acute onset perineal disease in previously healthy young men and is a urologic emergency.  Mike reviews a case series using the FDA adverse event reporting system and published case reports of SGLT-2 inhibitor use and Fournier’s gangrene.

Next, The Good Stuff segment.  John shares an educational point from former Toronto Raptor Tracy Murray on the use of thunder sticks.  John also highlights that Mike has recently defended his PhD – congratulations Mike!

Finally, Sheliza Halani interviews Dr. Danny Panisko and Dr. Gillian Spiegle for a special segment on teaching as a resident.  They discuss identifying teaching opportunities, behaviours for promoting understanding and retention, and empowering junior learners.

Like what you hear? Rate us on iTunes!  Chat with us on Twitter at @roundstable and tweet at Mike Fralick @fralickmike and Sheliza Halani @sheliza_halani.

Interested in helping us evaluate our podcast episodes? We’re currently recruiting a panel of residents to serve as regular reviewers for the show. If you’re interested, email wkwong@qmed.ca.

The Papers

1. tPA up to 9 hours: https://www.nejm.org/doi/full/10.1056/NEJMoa1813046

2. Nonfasting versus fasting lipids and coronary events: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2733560

3. Dabigatran for stroke prevention: https://www.nejm.org/doi/full/10.1056/NEJMoa1813959

4. Fournier’s gangrene and SGLT2 inhibitors: https://annals.org/aim/article-abstract/2732837/fournier-gangrene-associated-sodium-glucose-cotransporter-2-inhibitors-review-spontaneous

Special Segment

1. Teaching strategies: https://www.tandfonline.com/doi/full/10.3109/0142159X.2011.611838

2. Clinical teacher training: https://www.racgp.org.au/afpbackissues/2007/200712/200712molodysky.pdf

Good Stuff

1. Raptors: https://www.cbc.ca/radio/thecurrent/the-current-for-may-20-2019-1.5142470/original-toronto-raptor-tracy-murray-on-how-the-team-became-so-important-to-canadians-1.5142473

Music Credits

The Rounds Table Theme Music by Brendan Quinn, Creative Director and Composer, Vapor RMW

‘One Less Lonely Man’ by Nocturnal Spirits from Epidemic Sound

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