Abstract TP6: Current Trends in Thrombolytic Use for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Marquita Decker-Palmer ◽  
Ning Wu ◽  
Michele Biscossi ◽  
Sean I Savitz
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
The United States ◽  
Medicare Beneficiaries ◽  
Adherence To Guidelines ◽  
Current Trends ◽  
The Us ◽  
Hierarchical Categorization ◽  
Insured Patients ◽  
Rural Patients

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.

Abstract WMP50: Age-Specific Female-Male Disparities in Endovascular Thrombectomy Use for Acute Ischemic Stroke in the United States

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Hamidreza Saber ◽  
Amytis Towfighi ◽  
David S Liebeskind ◽  
Jeffrey L Saver
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Age Groups ◽  
Reperfusion Therapy ◽  
The United States ◽  
National Inpatient Sample ◽  
Endovascular Thrombectomy ◽  
Age Related ◽  
The Us ◽  
Age And Sex

Introduction: Studies have suggested sex-related and age-related variations in frequency of reperfusion therapy, but have been limited by constrained geographic scope, data from before the modern thrombectomy era, and incomplete exploration of sex-related differences in discrete age ranges. We therefore analyzed sex-, age-, and sex-age interaction in the frequency of endovascular thrombectomy (EVT) for acute ischemic stroke in the US National Inpatient Sample. Methods: In the National Inpatient Sample , we identified all adult ischemic stroke EVT hospitalizations from 2010-2016, using ICD-9-CM and ICD-10-CM codes. Patient age was categorized as: <50y, 50-59y, 60-69y, 70-79y and ≥80ys. Rates of use of EVT were assessed standardized to the 2010 US Census population. Results: Among 50,573 EVT hospitalizations, 50.1% were female. The number of EVTs increased from 4091 in 2010 to 12,875 in 2016. Over the entire 7y time period, a sex-age interaction was noted: 49% in <50y; 37% in 50-59y; 35% in 60-69y; 53% in 70-79y; and 66% in ≥80y. This sex-age interaction was present as well for EVT rates per 100,000 individuals in the population, with the total ratio of female to male rate of EVT per 100,000: 0.93 for in <50y; 0.52 in 50-59y; 0.58 in 60-69y; 0.91 in 70-79y; and 1.1 in ≥80y. EVT utilization rates increased substantially over time in both men and women in all age groups. However, the ratio of women to men per 100,000 receiving EVT changed for only one age range, decreasing among <50y from 0.98 in 2010 to 0.79 in 2016 (P<0.05). Conclusion: While half of all endovascular thrombectomies in the US are performed in women, there are major age-related sex-specific variations in EVT rates, with rates of EVT much lower among women than men in 50-70 age group. Determinants of these age-specific female-male disparities in EVT treatment merit detailed investigation. Figure: Age- and sex-specific female to male thrombectomy utilization rates.

Abstract WMP32: Variation in the Rates of Acute Ischemic Stroke Transfers Between Hospitals in the United States

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Syed F Ali ◽  
Gregg Fonarow ◽  
Eric Smith ◽  
Li Liang ◽  
Robert Sutter ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
High Volume ◽  
The United States ◽  
Teaching Hospitals ◽  
Large Sample Size ◽  
Stroke Registry ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Us ◽  
Iv Tpa

Background: Many patients are transferred from emergency departments or inpatient units to stroke centers for advanced acute ischemic stroke (AIS) care, especially after intravenous tissue plasminogen activator (tPA). We sought to determine variation in the rates of AIS patient transfer in the US. Methods: Using data from the national Get With The Guidelines-Stroke registry, we analyzed AIS cases from 01/2010 to 03/14. Transfer-in was defined as transfer of AIS patients from other hospitals. Due to large sample size, instead of p-values, standardized differences were reported and a map of transfer-in rates across the US constructed. Results: Of the 970,390 patients discharged from 1,646 hospitals in the US, 87% were admitted via the ER or direct admission (front door) vs. 13% transferred-in. While most hospitals (61%) had transfer-in rates of < 5% of all AIS patients, a minority (17%) had high (>15%) transfer-in rates. High transfer-in hospitals were more often in the Midwest, were larger, and had higher annual AIS and IV tPA case volumes, and were also more often teaching hospitals and stroke centers (primary or comprehensive) (Table and Figure).. IV tPA was used more frequently in eligible patients in high-volume transfer-in hospitals (Table); otherwise, stroke quality of care was similar. Conclusions: There is significant regional- and state-level variability in the transfer of AIS patients. This may reflect differences in resource availability and the distribution of smaller, under-resourced hospitals that frequently transfer patients for advanced care after stabilization. Additional research is warranted to understand this variation.

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

Stroke ◽  
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.

History and Current Trends in the Electronic Cigarette Retail Marketplace in the United States: 2010–2016

2018 ◽  
Vol 22 (5) ◽  
pp. 843-847 ◽  
Author(s):  
Jennifer Cantrell ◽  
Jidong Huang ◽  
Marisa Greenberg ◽  
Jeffrey Willett ◽  
Elizabeth Hair ◽  
...  
Keyword(s):  
Tobacco Industry ◽  
The United States ◽  
Retail Market ◽  
Current Trends ◽  
Published Evidence ◽  
The Us ◽  
Industry Response ◽  
Market Trends ◽  
The Impact ◽  
Over Time

Abstract Introduction The US market for electronic nicotine delivery systems (ENDS) has grown rapidly in the last decade. There is limited published evidence examining changes in the ENDS marketplace prior to the US Food and Drug Administration’s (FDA) deeming rule in 2016. This study describes US ENDS retail market trends from 2010 to 2016. Methods National data were obtained from Nielsen retail scanners for five product types: (1) disposables, (2) rechargeables, (3) cartridge replacements, (4) e-liquid bottle refills, and (5) specialty vapor products. We examined dollar sales, volume, price, brand, and flavor. Results Adjusted national sales increased from $11.6 million in 2010 to $751.2 million in 2016. The annual rate of sales growth rapidly increased before slowing through 2015. The rate of growth spiked in 2016. Market share for menthol products and other assorted flavors increased from 20% in 2010 to 52.1% by 2016. NJOY’s early market dominance shifted as tobacco industry brands entered the market and eventually captured 87.8% of share by 2016. Rechargeables and accompanying products comprised an increased proportion of total volume sold over time while disposable volume declined. Specialty vapor products appeared at retail in 2015. Conclusions Findings show strong early growth in the ENDS retail market followed by considerable slowing over time, despite a slight uptick in 2016. Trends reflect shifts to flavored products, newer generation “open-system” devices, lower prices, and tobacco industry brands. This study provides a baseline against which to compare the impact of FDA’s 2016 deeming rule and future actions on the ENDS marketplace. Implications This study uses market scanner data from US retail outlets to describe trends in the ENDS retail market from 2010 to 2016, providing a baseline against which to compare the impact of FDA’s 2016 deeming rule and future actions on the ENDS marketplace. Understanding historical market trends is valuable in assessing how future regulatory efforts and advances in ENDS technology may impact industry response and consumer uptake and use.

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

Stroke ◽  
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.

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

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.

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

Stroke ◽  
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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