Prioritizing interventions to improve rates of thrombolysis for ischemic stroke.
BACKGROUND
Thrombolytic treatment has been shown to be effective in the treatment of ischemic stroke when initiated within 3 hours of symptom onset, yet few patients receive thrombolytics.


OBJECTIVE
To estimate expected increases in use of thrombolytics for ischemic stroke given the following interventions: educating patients to present earlier, optimizing Emergency Medical Services (EMS) response/transport times, optimizing hospital systems, and extending the treatment window.


METHODS
As part of a Centers for Disease Control-sponsored Coverdell Acute Stroke Pilot Registry, the authors prospectively identified all patients with an initial diagnosis of ischemic stroke at 11 hospitals in California over a 3-month period. Timing of symptom onset, EMS response, hospital arrival, treatment, and reasons for nontreatment were evaluated, and hypothetical treatment rates for thrombolysis for interventions on the stroke-care continuum were derived based on observed rates of eligibility and treatment.


RESULTS
Of 374 patients with ischemic stroke, 88 (23.5%) arrived at the emergency department within 3 hours of symptom onset, of whom 16 (4.3%) received thrombolysis. If all patients with known onset times had called 911 immediately, the expected overall rate of thrombolytic treatment within 3 hours would have increased from 4.3 to 28.6%. Expected rates of thrombolysis were lower for other interventions: instantaneous prehospital response 5.5%, perfect hospital care 11.5%, and extension of time window to 6 hours 8.3%. If all patients with known onset had arrived within 1 hour and been optimally treated, 57% could have been treated.


CONCLUSIONS
Campaigns that educate patients to seek treatment sooner should be major components of system-wide interventions to increase rates of thrombolysis for acute ischemic stroke.
D002545:Brain Ischemia / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D002140:California / Q000453:epidemiology; D002487:Centers for Disease Control and Prevention, U.S.; D000075202:Contraindications; D004363:Drug Utilization; D042241:Early Diagnosis; D004630:Emergencies; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D006292:Health Priorities; D015277:Hotlines; D006801:Humans; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010353:Patient Education as Topic; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D012042:Registries; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D014187:Transportation of Patients / Q000706:statistics & numerical data; D014481:United States
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator