title: Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes.
abstract: BACKGROUND
  The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and guidelines recommend an arrival to treatment initiation (door-to-needle) time of ≤60 minutes.
  
  
  RESULTS
  Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1082 hospitals participating in the Get With the Guidelines-Stroke Program from April 1, 2003, to September 30, 2009 were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. Among 25 504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60 minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 (P<0.0001). Despite similar stroke severity, in-hospital mortality was lower (adjusted odds ratio, 0.78; 95% confidence interval, 0.69 to 0.90; P<0.0003) and symptomatic intracranial hemorrhage was less frequent (4.7% versus 5.6%; P<0.0017) for patients with door-to-needle times ≤60 minutes compared with patients with door-to-needle times >60 minutes.
  
  
  CONCLUSIONS
  Fewer than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke.
authors.affiliation: Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, 10833 LeConte Ave., Los Angeles, CA 90095-1679, USA. gfonarow@mednet.ucla.edu
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Saver
authors.forename: Mathew J
authors.initials: MJ
authors.lastname: Reeves
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.forename: Maria V
authors.initials: MV
authors.lastname: Grau-Sepulveda
authors.forename: DaiWai M
authors.initials: DM
authors.lastname: Olson
authors.forename: Adrian F
authors.initials: AF
authors.lastname: Hernandez
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D000572:American Heart Association; D002545:Brain Ischemia / Q000188:drug therapy* / Q000453:epidemiology; D004632:Emergency Medical Services / Q000592:standards*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy* / Q000453:epidemiology; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014481:United States / Q000453:epidemiology
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator