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Most U.S. tPA-eligible stroke patients now get treated within an hour

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Thrombolytic-goal achievement documents real progress

The Target: Stroke and Get With The Guidelines-Stroke programs should be commended for the very impressive achievements they have made in improved delivery of thrombolytic therapy to acute ischemic stroke patients. What’s happened over the past decade in the speed of delivery of tissue plasminogen activator for treating U.S. stroke patients has been a real success story.

Dr. Bruce Ovbiagele, chief of staff, San Francisco Veterans Affairs Health Care System Mitchel L. Zoler/MDedge News

Dr. Bruce Ovbiagele

Tissue plasminogen activator received U.S. approval for acute stroke treatment in 1996, but during the first 10 years or so, it hardly moved. It took programs like Target: Stroke to make rapid thrombolysis a true part of routine care. Over the past 10 years, more clinicians have become comfortable with a systematic approach to care delivery; it has been a great transformation. The successes with thrombolytic therapy give us a model to apply to other aspects of acute stroke care that could also benefit from a systematic approach. Endovascular thrombectomy, for example, has been able to piggyback on the assessment, triage, and delivery systems that were first developed to deal with thrombolytic therapy.

Programs like Get With The Guidelines and Target: Stroke have proven their value, but a significant barrier remains to bringing this program to all U.S. stroke patients and to all U.S. hospitals that treat stroke patients. That barrier is resources. Participating hospitals need to meet certain data-collection standards, but some U.S. hospitals do not have the resources to do this.

Bruce Ovbiagele, MD , is a neurologist and chief of staff for the San Francisco Veterans Affairs Health Care System. He had no disclosures. He made these comments in an interview.



– The speed at which eligible U.S. patients with acute ischemic stroke receive thrombolytic therapy has surged in recent years, and by the third quarter of 2018, a nationwide U.S. program aimed at boosting the number of stroke patients who receive thrombolysis in a timely way met its most recent speed targets.

Dr. Gregg C. Fonarow is a professor of medicine and co-chief of cardiology at the University of California, Los Angeles. Mitchel L. Zoler/MDedge News

Dr. Gregg C. Fonarow

By the second half of last year, 75% of acute ischemic stroke patients treated at any of the 913 U.S. hospitals in the Get With The Guidelines-Stroke program received intravenous tissue plasminogen activator (tPA; Alteplase) within 60 minutes of their hospital arrival (their door-to-needle time (DTN), and 52% received tPA with a DTN time of 45 minutes or less. These levels met the treatment-speed goals set by the second phase of the Target: Stroke program, which called for delivering tPA to 75% of appropriate stroke patients within a DTN time of 60 minutes, and within 45 minutes in at least 50% of patients, Gregg C. Fonarow, MD, and his associates reported at the International Stroke Conference, sponsored by the American Heart Association.

The analyses they reported also documented how these most recent gains in thrombolytic speed played out in improved patient outcomes. During phase 2 of Target: Stroke, which ran from January 2014 to September 2018, 85,078 U.S. patients received tPA at one of the participating hospitals. During those 4 years, the rate of in-hospital mortality was 6.0%, half the patients were discharged home, 53% could ambulate independently, and the rate of intracerebral hemorrhage (ICH) was 3.5%. The researchers compared these clinical event rates with the rates from 24,603 tPA-treated patients during 2003-2009, before the Target: Stroke campaign began. After adjustment for many potential confounders, the more recently treated cohort had a 31% relative risk reduction in in-hospital mortality, a 43% relative increase in being discharged home, a 40% relative increase in independent ambulation, and a 32% relative risk reduction in the rate of symptomatic ICH. All these between-group differences were statistically significant.

“We were hoping that, by improving DTN times we could achieve improved outcomes, but often in quality-improvement research – even when the process of care improves – the gains in outcomes don’t necessarily match expectations. Fortunately, with Target: Stroke, the remarkable improvements in timely treatment translated to remarkable improvements in clinical outcomes,” Dr. Fonarow said in an interview. “These are substantial, clinically relevant improvements in clinical outcomes for patients with acute ischemic stroke. As a result of the program, more than 100,000 acute ischemic stroke patients received much more timely acute ischemic stroke care and achieved far better clinical outcomes.”

During the 2003-2018 period reviewed, the percentage of presenting acute ischemic stroke patients who received tPA treatment at the 913 Get With The Guidelines hospitals that participated in the Target: Stroke program (and so had reviewable data) throughout all three periods rose from 6% during 2003-2009 (prestudy) to 8% during 2010-2013 (phase 1), and to 12% during 2014-2018 (phase 2). The percentages of these patients who received the drug within 60 minutes were 27% during 2003-2009, 43% during 2010-2013, and 68% during the entire 2014-2018 period, culminating in the 75% rate during July-September 2018, reported Dr. Fonarow, professor of medicine and cochief of cardiology at the University of California, Los Angeles.

Dr. Fonarow attributed the drop in the rate of ICH – from 5.7% during 2003-2009, to 4.4% during 2010-2013, and down to 3.5% during 2014-2018 – to the faster delivery of tPA. “With faster treatment, there is less ischemic brain and vascular damage and thus a lower likelihood of ICH as a complication of tPA,” he explained.

The Target: Stroke program achieved these gains in speedier thrombolytic treatment (and better recognition of eligible patients) through educational and promotional activities including dissemination of best practices. Notable best practices have included EMS prenotification of hospitals before they arrive with a stroke patient, direct transport of patients to a brain imaging scanner, premix of tPA, initiation of tPA in the brain imaging suite, and prompt data feedback, Dr. Fonarow said.

The Get With The Guidelines-Stroke and Target: Stroke programs now involve more than 2,100 U.S. hospitals, and they are able to deliver emergency care to roughly 70% of U.S. acute ischemic stroke patients, he noted.

With achievement of Target: Stroke’s phase 2 goals, the program announced its launch of a third phase, with new treatment goals: Initiation of thrombolytic treatment to 85% of eligible patients within 60 minutes, to 75% within 45 minutes, and to 50% within 30 minutes. The phase 3 Target: Stroke program also for the first time includes treatment goals for delivery of endovascular thrombectomy treatment.

SOURCE: Fonarow GC et al. ISC 2019, Abstract LBP9.

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