Introduction:
Alteplase is approved in the United States for acute ischemic stroke (AIS). Guidelines recommend IV weight-based alteplase dosing for AIS treatment with or without endovascular therapy (EVT). With increasing use of EVT, current thrombolytic use and dosing practices in AIS are poorly understood. This study assesses current and historical trends in thrombolytic use.
Methods:
All patients who received alteplase from 2007 to 2017 in the US Premier Hospital database were included. Hierarchical categorization identified indications by the presence of primary or secondary diagnoses including AIS > pulmonary embolism (PE) > myocardial infarction (MI) > or other. Patients undergoing EVT were subcategorized. Dosing was estimated by vial size. Demographics were analyzed descriptively.
Results:
Of 78,216 patients included, 33,530 (43%) had AIS, 7442 (9%) PE, 1696 (2%) MI, and 35,548 (45%) off-label indications. Patients with AIS had mean age of 68, and 2409 (7%) received alteplase + EVT. Of those with alteplase + EVT, 1428 (59%) were solely Medicare beneficiaries and 600 (25%) had solely commercial insurance vs 19,572 (63%) Medicare and 6585 (21%) commercially insured patients receiving alteplase alone. Only 37 patients (2%) with AIS receiving alteplase + EVT had care at rural hospitals, whereas 2946 rural patients with AIS (9%) received alteplase alone. Before 2011, EVT was associated with use of 50-mg vials of alteplase to treat AIS (Fig). After 2011, more patients with AIS receiving EVT had 100-mg vials of alteplase, consistent with dosing closer to the 90-mg maximum.
Conclusions:
AIS is the most common indication for current alteplase use. Since 2011, weight-based dosing has been widely adopted for treatment with and without EVT, which represents adherence to guidelines. Differences in payer mix and rurality among patients receiving alteplase + EVT may represent opportunities to improve access to care.
Current trends in sonothrombolysis for acute ischemic stroke
