Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry

Controversies in Thrombolysis

PURPOSE OF REVIEW

The purpose of the review is to examine recent evidence on the effects of intravenous thrombolysis and identify the remaining uncertainties.

RECENT FINDINGS

We review the results of two large trials (the third International Stroke Trial (IST-3) and The Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED)) and the publications from the individual patient data analyses of the trials of alteplase conducted by the Stroke Thrombolysis Trialists Collaboration. Despite about a 2% risk of fatal intracerebral haemorrhage, on average, adult patients of all ages treated with 0.9 mg/kg alteplase within 4.5 h will have better long-term functional outcome. The use of a lower dose of alteplase (0.6 mg/kg) is associated with a lower risk of haemorrhage but its effect on functional outcome has not been proven to be non-inferior to standard dose therapy. Some clinicians feel confident to treat selected patients who present beyond 4.5 h or have unknown time of onset, but many also agree that the current trials and other research is needed to reliably define the optimum imaging methods and treatment eligibility criteria.

The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care

The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.

Individual and System Contributions to Race and Sex Disparities in Thrombolysis Use for Stroke Patients in the United States

BACKGROUND AND PURPOSE

Intravenous thrombolysis (IVT) is underutilized in ethnic minorities and women. To disentangle individual and system-based factors determining disparities in IVT use, we investigated race/sex differences in IVT utilization among hospitals serving varying proportions of minority patients.

METHODS

Ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of minority patients admitted with stroke (<25% minority patients [white hospitals], 25% to 50% minority patients [mixed hospitals], or >50% minority patients [minority hospitals]). Logistic regression was used to evaluate the association between race/sex and IVT use within and between the different hospital strata.

RESULTS

Among 337 201 stroke admissions, white men had the highest odds of IVT among all race/sex groups in any hospital strata, and the odds of IVT for white men did not differ by hospital strata. For white women and minority men, the odds of IVT were significantly lower in minority hospitals compared with white hospitals (odds ratio, 0.83; 95% confidence interval, 0.71-0.97, for white women; and odds ratio, 0.82; 95% confidence interval, 0.69-0.99, for minority men). Race disparities in IVT use among women were observed in white hospitals (odds ratio, 0.88; 95% confidence interval, 0.78-0.99, in minority compared with white women), but not in minority hospitals (odds ratio, 0.94, 95% confidence interval, 0.82-1.09). Sex disparities in IVT use were observed among whites but not among minorities.

CONCLUSIONS

Minority men and white women have significantly lower odds of IVT in minority hospitals compared with white hospitals. IVT use in white men does not differ by hospital strata.