137-01: Gender Differences in the Rates of Hospitalizations for Acute Ischemic Stroke Among Patients with Atrial Fibrillation In The United States: A 15 Year Experience Involving 1.1 Million Patients

Background: Large scale data on atrial fibrillation (AF) prevalence in acute ischemic stroke (AIS) is sparse since approval of dabigatran for non-valvular AF in 2010. We studied recent trends in prevalence of AF in AIS and transient ischemic attack (TIA) in the United States (US) and association of AF with in-hospital mortality, cost and length of stay (LOS) in AIS. Methods: Adults admitted to US hospitals from 2007-2012 with diagnosis of AIS (n=3,427,806) and TIA (n=502,820) were identified from the Nationwide Inpatient Sample. Weighted prevalence of AF in AIS and TIA by demographics and region was computed. Multivariate logistic regression was used to evaluate association of AF with other clinical factors and mortality in AIS. Association of AF with LOS and cost was assessed using generalized linear models. Results: AF prevalence increased by 11.5% in AIS (22%-24.5%, p<0.001) and by 29% in TIA (13.5%-17.4%, p<0.001) from 2007-2012. AF prevalence varied by age (AIS: 7% in 50-59yo vs 38% in >80yo; TIA: 5% in 50-59yo vs 27% in >80yo), sex (AIS: 20% in M vs 25% in F); TIA: 16% in M vs 15% in F), race (AIS: whites 26% vs blacks 12%) and region (AIS: Northeast 25% vs South 21%). AF prevalence increased in all subgroups over time (p<0.001) except AIS <40yo and TIA<50yo (Figure 1). Advancing age, female sex, white race, high income, Medicare insurance, CHA 2 DS 2 -VASc score and large hospital size were associated with increased odds of AF in AIS. AF was positively associated with death (OR=1.60, 95%CI 1.56-1.64) but mortality in AIS with AF decreased from 13.2% in 2007 to 10.7% in 2012 (p<0.001). AF was associated with increased cost of $2,631 and LOS 1.1 days in AIS. Conclusion: Prevalence of AF in AIS and TIA has continued to increase. Disparity in AF prevalence in AIS and TIA exists by patient and hospital factors. AF is associated with increased mortality, LOS and hospital cost in AIS but mortality in AIS with AF is decreasing. More AIS preventive efforts are needed in AF patients especially in the elderly.

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Achieving More Rapid Door-to-Needle Times and Improved Outcomes in Acute Ischemic Stroke in a Nationwide Quality Improvement Intervention

Stroke ◽

10.1161/strokeaha.121.035853 ◽

2021 ◽

Author(s):

Ying Xian ◽

Haolin Xu ◽

Eric E. Smith ◽

Jeffrey L. Saver ◽

Mathew J. Reeves ◽

...

Keyword(s):

United States ◽

Quality Improvement ◽

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Phase I ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

The United States

Background and Purpose: The benefits of tPA (tissue-type plasminogen activator) in acute ischemic stroke are time-dependent. However, delivery of thrombolytic therapy rapidly after hospital arrival was initially occurring infrequently in hospitals in the United States, discrepant with national guidelines. Methods: We evaluated door-to-needle (DTN) times and clinical outcomes among patients with acute ischemic stroke receiving tPA before and after initiation of 2 successive nationwide quality improvement initiatives: Target: Stroke Phase I (2010–2013) and Target: Stroke Phase II (2014–2018) from 913 Get With The Guidelines-Stroke hospitals in the United States between April 2003 and September 2018. Results: Among 154 221 patients receiving tPA within 3 hours of stroke symptom onset (median age 72 years, 50.1% female), median DTN times decreased from 78 minutes (interquartile range, 60–98) preintervention, to 66 minutes (51–87) during Phase I, and 50 minutes (37–66) during Phase II ( P <0.001). Proportions of patients with DTN ≤60 minutes increased from 26.4% to 42.7% to 68.6% ( P <0.001). Proportions of patients with DTN ≤45 minutes increased from 10.1% to 17.7% to 41.4% ( P <0.001). By the end of the second intervention, 75.4% and 51.7% patients achieved 60-minute and 45-minute DTN goals. Compared with the preintervention period, hospitals during the second intervention period (2014–2018) achieved higher rates of tPA use (11.7% versus 5.6%; adjusted odds ratio, 2.43 [95% CI, 2.31–2.56]), lower in-hospital mortality (6.0% versus 10.0%; adjusted odds ratio, 0.69 [0.64–0.73]), fewer bleeding complication (3.4% versus 5.5%; adjusted odds ratio, 0.68 [0.62–0.74]), and higher rates of discharge to home (49.6% versus 35.7%; adjusted odds ratio, 1.43 [1.38–1.50]). Similar findings were found in sensitivity analyses of 185 501 patients receiving tPA within 4.5 hours of symptom onset. Conclusions: A nationwide quality improvement program for acute ischemic stroke was associated with substantial improvement in the timeliness of thrombolytic therapy start, increased thrombolytic treatment, and improved clinical outcomes.

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Rate of deep-vein thrombosis and pulmonary embolism during the care continuum in patients with acute ischemic stroke in the United States

BMC Neurology ◽

10.1186/1471-2377-13-17 ◽

2013 ◽

Vol 13 (1) ◽

Cited By ~ 10

Author(s):

Alpesh N Amin ◽

Jay Lin ◽

Stephen Thompson ◽

Daniel Wiederkehr

Keyword(s):

United States ◽

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

The United States ◽

Care Continuum ◽

Vein Thrombosis ◽

Deep Vein

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Burden of Atrial Fibrillation–Associated Ischemic Stroke in the United States

JACC: Clinical Electrophysiology ◽

10.1016/j.jacep.2018.02.021 ◽

2018 ◽

Vol 4 (5) ◽

pp. 618-625 ◽

Cited By ~ 24

Author(s):

Mohamad Alkhouli ◽

Fahad Alqahtani ◽

Sami Aljohani ◽

Muhammad Alvi ◽

David R. Holmes

Keyword(s):

United States ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

The United States

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Abstract P12: Alteplase Reduces Mortality in Patients With Ischemic Stroke and Atrial Fibrillation: Analysis of the IAC Study

Stroke ◽

10.1161/str.52.suppl_1.p12 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Shadi Yaghi ◽

Eva Mistry ◽

Adam H De Havenon ◽

Christopher Leon Guerrero ◽

Amre Nouh ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Intravenous Thrombolysis ◽

The United States ◽

Hemorrhagic Transformation ◽

Stroke Patients ◽

Increased Risk ◽

Significant Difference

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

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Abstract 504: Regional Variations of Ischemic Stroke in The United States

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.37.suppl_1.504 ◽

2017 ◽

Vol 37 (suppl_1) ◽

Author(s):

Prateeth Pati ◽

Adnan Khalif ◽

Balaji Shanmugam

Keyword(s):

United States ◽

Ischemic Stroke ◽

Seasonal Variation ◽

Acute Ischemic Stroke ◽

Geographic Distribution ◽

The United States ◽

Categorical Variables ◽

The South ◽

Admission Rates ◽

Chi Square Analysis

Geographic Distribution of Acute Ischemic Stroke admissions in the United States Background: The geographic distribution of acute ischemic stroke in the United States has not been evaluated, unlike the association shown with acute MI by Patel et al., (International Journal of Cardiology, 2014, 172.3). Our study looked at the geographic distribution and seasonal variation of acute ischemic stroke using the National Inpatient Sample (NIS) from 2011 - 2013. Methods: Adult admissions with a primary diagnosis of acute ischemic stroke were extracted from the NIS database using the ICD 9 code 434.91 from 2011 - 2013. Admission information included hospital region (West, South, Mid-Atlantic and Northwest) and seasonal admission rates (Winter=December-February, Spring=March-May, Summer=June-August, Fall=September-November). A Chi square analysis was used to analyze differences in categorical variables (we assumed a normal distribution of 25% per region). Results: A total of 120714 admissions were identified (weighted = 603361). There were more cases of acute ischemic stroke in the South (41.52 percent of admissions) compared to the mid Atlantic (21.4), Northwest (17.98) or West (19.08) with a p value < 0.0001. Each year between 2011 to 2013 showed a higher rate of admissions for acute ischemic stroke in the South. Taking the years into summation showed no statistically significant difference in seasonal variation in any of the regions. Conclusion: Our study shows a higher number of admissions for acute ischemic stroke in the South, but failed to show any seasonal differences. However, there are several studies that suggest a preponderance of admissions for acute myocardial infarction during the winter season, Spencer et al., (Journal of the American College of Cardiology, 1998, 31.2.) Further studies are needed to identify why there is a significant regional difference in the admission rates for acute ischemic stroke.

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Abstract 45: Thrombolytic Treatment for In-Hospital Ischemic Strokes in United States

Stroke ◽

10.1161/str.44.suppl_1.a45 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Tenbit Emiru ◽

Malik M Adil ◽

Adnan I Qureshi

Keyword(s):

United States ◽

Ischemic Stroke ◽

Length Of Stay ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Clinical Characteristics ◽

The United States ◽

Treated Group ◽

Hospital Charges ◽

Thrombolytic Treatment

BACKGROUND: Despite the recent emphasis on protocols for emergent triage and treatment of in-hospital acute ischemic stroke, there is little data on rates and outcomes of patients receiving thrombolytics for in-hospital ischemic strokes. OBJECTIVE: To determine the rates of in-hospital ischemic stroke treated with thrombolytics and to compare outcomes with patients treated with thrombolytics on admission. DESIGN/METHODS: We analyzed a seven-year data (2002-2009) from the National Inpatient Survey (NIS), a nationally representative inpatient database in the United States. We identified patients who had in-hospital ischemic strokes (defined by thrombolytic treatment after one day of hospitalization) and those who received thrombolytics on the admission day. We compared demographics, baseline clinical characteristics, in hospital complications, length of stay, hospitalization charges, and discharge disposition, between the two patient groups. RESULT: A total of 18036 (21.5%) and 65912 (78.5%) patients received thrombolytics for in-hospital and on admission acute ischemic stroke, respectively. In hospital complications such as pneumonia (5.0% vs. 3.4%, p=0.0006), deep venous thrombosis (1.9% vs. 0.6%, p<0.0001) and pulmonary embolism (0.8% vs. 0.4%, p=0.01) were significantly higher in the in-hospital group compared to on admission thrombolytic treated group. Hospital length of stay and mean hospital charges were not different between the two groups. Patients who had in-hospital strokes had had higher rates of in hospital mortality (12.1% vs. 10.6%, p=0.02). In a multivariate analysis, in-hospital thrombolytic treated group had higher in-hospital mortality after adjustment for age, gender and baseline clinical characteristics (odds ratio 0.84, 95% confidence interval 0.74-0.95, p=0.008). CONCLUSION/RELEVANCE: In current practice, one out of every five acute ischemic stroke patients treated with thrombolytics is receiving treatment for in-hospital strokes. The higher mortality and complicated hospitalization in such patients needs to be recognized.

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Disparities in the Use of Mechanical Thrombectomy Alone Compared with Adjunctive Intravenous Thrombolysis in Acute Ischemic Stroke in the United States

American Journal of Neuroradiology ◽

10.3174/ajnr.a7332 ◽

2021 ◽

Author(s):

W. Wahood ◽

A.A. Rizvi ◽

Y. Alexander ◽

M.A. Alvi ◽

K.R. Rajjoub ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

The United States

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Abstract TP77: Race/Ethnic Disparity Trends in tPA Administration in the United States

Stroke ◽

10.1161/str.47.suppl_1.tp77 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Michelle P Lin ◽

Steven Cen ◽

Amytis Towfighi ◽

May Kim-Tenser ◽

William Mack ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Rate Ratio ◽

The United States ◽

Racial Groups ◽

Primary Analysis ◽

Targeted Interventions ◽

Yearly Change ◽

Administration Rate

Introduction: Prior studies have shown racial disparities in tPA use for acute ischemic stroke. With the implementation of nationwide quality improvement measures, we sought to describe the temporal change in racial disparity in tPA administration. Hypothesis: Disparity in tPA administration improved across all racial groups in the past decade Methods: Data were obtained from all US states that contributed to the Nationwide Inpatient Sample. All patients (N=5,932,175) admitted to hospitals between 2000 and 2010 with a discharge diagnosis of ischemic stroke (ICD9 codes) were included. Primary analysis was the proportion of patients who received tPA administration stratified by race (white, black, Hispanic, Asian) temporally. Survey-weighted Poisson regression was used to estimate the rate ratio and compare the trend for yearly change between race categories. Results: Of the patients with ischemic stroke, 55.4% were white, black 11.89%, Hispanic 5.32%, Asian 1.89%, others 1.77%, missing race 23.31%. tPA administration rate increased from 2000 to 2010 regardless of race. In 2000, tPA administration rate was 0.96%, 0.40%, 0.73%, 0.59% in white, black, Hispanic, Asian, respectively. In 2010, tPA administration rate was 4.0%, 2.14%, 2.09%, 2.13% respectively. The relative change was the greatest in black with rate ratio of 6.7 (5.95-7.54), compared to other racial groups, Asian 5.36 (4.23-6.78), Hispanic 3.93 (3.42-4.51), and white 3.88 (3.74-4.03). Conclusions: Over the last decade, the rate of tPA administration for acute ischemic stroke in the United States have increased for every racial group. There is a lasting but improved disparity in tPA administration in non-white race. Targeted interventions designed to increase treatment and close disparity gap focusing on culturally tailored education and communications to address barriers need to be further explored.

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