Treatment With Tissue Plasminogen Activator in the Golden Hour and the Shape of the 4.5-Hour Time-Benefit Curve in the National United States Get With The Guidelines-Stroke Population

Background: Target: Stroke was initiated in 2010 as a national quality improvement effort. This American Stroke Association campaign gave tools, consulting and data analysis to hospitals to improve door to needle time with tissue plasminogen activator (tPA). Along with this effort, the state of Wisconsin continued to work on a stroke system of care as well as education on tPA warnings versus absolute contraindications. Methods: This study looked at an average of 40 Wisconsin hospitals and 26,185 ischemic stroke patients in Get With The Guidelines- Stroke over a five year period to determine if there were trends in how hospitals documented contraindications for tPA. Results: From 2010 to 2014 Advanced Age and Age >80 decreased as a tPA contraindication by 7.3% and 4.6% respectively. Rapid Improvement decreased from 38% of the tPA contraindications to 35.1% over this time period. Hospitals also listed a 2.5% increase in the amount of patients receiving tPA in an outside hospital before transfer. Conclusions: Through efforts such as Target: Stroke, statewide education and systems of care work, Wisconsin hospitals have improved the door to needle time for eligible patients from 18.1% in 2010 to 66.8% under 60 minutes. The data shows that advanced age is not used as often as a contraindication assuming education of age being a warning and not an absolute contraindication has had some effect on treatment decisions. It can also be assumed that referral hospitals are giving more tPA and transferring when necessary as hospitals have increased listing tPA at an outside hospital as a contraindication. Rapid Improvement has fluctuated but is at a five year low

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Contraindications with recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke population

Neurology Psychiatry and Brain Research ◽

10.1016/j.npbr.2017.11.002 ◽

2018 ◽

Vol 27 ◽

pp. 6-11 ◽

Cited By ~ 5

Author(s):

Shuler R. Polk ◽

Clay Stafford ◽

Alyssa Adkins ◽

Jessica Efird ◽

Michael Colello ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Recombinant Tissue Plasminogen Activator ◽

Stroke Population ◽

Tissue Plasminogen

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Patenting of recombinant proteins: An analysis of tissue plasminogen activator (t-PA) in Europe, The United States and Japan

Research Policy ◽

10.1016/s0048-7333(98)80001-2 ◽

1995 ◽

Vol 24 (4) ◽

pp. 645-663 ◽

Cited By ~ 6

Author(s):

Sandra M. Thomas ◽

Keiko Kimura ◽

Julian F. Burke

Keyword(s):

United States ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Recombinant Proteins ◽

The United States ◽

Tissue Plasminogen

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Economic Benefit of Increasing Utilization of Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke in the United States

Stroke ◽

10.1161/01.str.0000185699.37843.14 ◽

2005 ◽

Vol 36 (11) ◽

pp. 2500-2503 ◽

Cited By ~ 78

Author(s):

Bart M. Demaerschalk ◽

Todd R. Yip

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Economic Benefit ◽

The United States ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen

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Abstract 159: Treatment with Intravenous Tissue Plasminogen Activator in the “Golden Hour” in the National US Get With The Guidelines-Stroke Population

Stroke ◽

10.1161/str.46.suppl_1.159 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Jeffrey L Saver ◽

Gregg C Fonarow ◽

Eric E Smith ◽

Mathew J Reeves ◽

Digvijaya Navalkele ◽

...

Keyword(s):

Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Time Window ◽

Systems Of Care ◽

Stroke Treatment ◽

Golden Hour ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Independent Ambulation

Background: Innovations in prehospital and Emergency Department systems of care increasingly enable IV tissue plasminogen activator (tPA) delivery in the first 60 minutes after onset, a time window not tested in placebo-controlled clinical trials. We sought to characterize efficacy and safety outcomes when tPA is delivered in the “golden hour.” Methods: We analyzed 65,384 acute ischemic stroke patients treated with tPA within 4.5 hours of symptom onset in 1456 hospitals participating in GWTG-Stroke from Jan 2009 to Sept 2013. Multivariable logistic regression modeling was employed to evaluate the independent impact of treatment within 60 minutes of onset on outcome. Results: 878 patients (1.3%) received lytic therapy within 60 minutes of onset, versus 6490 (9.9%) in 61-90m, 46,457 (71.1%) in 91-180m, and 11,559 (17.7%) in 181-270m. Independent patient-level factors associated with treatment in the golden hour were older age (aOR 1.15 per 5 years over age 65), higher NIHSS (aOR, 1.04 per scale point), non-EMS arrival (aOR 1.59), and arrival during on hours (aOR 1.61). Hospital level predictors were higher tPA volume (aOR 1.08 per 5 cases), non-PSC (aOR 1.27), and Western region (aOR 1.38 vs Northeast). Compared with the 61-270m window, treatment within 0-60m was associated with increased independent ambulation at d/c, aOR 1.22 (95% CI 1.03-1.45); discharge to home, aOR 1.25 (1.07-1.45); and being disability-free at d/c, aOR 1.72 (95% CI 1.21-2.46, mRS 0-1). No differences were noted in in-hospital mortality or SICH. Considering all discharge mRS transitions, golden hour treatment showed greatest impact at mRS 0-1 vs 2-6 (Figure). Conclusions: Ischemic stroke treatment with IV tPA in the golden hour is associated with more frequent independent ambulation at discharge, discharge to home, and, especially, being disability free at discharge. These findings support intensive efforts, including Target: Stroke and prehospital thrombolysis, to speed treatment initiation.

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