title: Use of tissue-type plasminogen activator before and after publication of the European Cooperative Acute Stroke Study III in Get With The Guidelines-Stroke.
abstract: BACKGROUND
  The European Cooperative Acute Stroke Study (ECASS) III demonstrated benefit to expanding the intravenous tissue-type plasminogen activator (tPA) window from 3 to 4.5 hours for patients with acute ischemic stroke (AIS). We investigated how this trial influenced use of tPA in clinical practice.
  
  
  RESULTS
  Using the Get With The Guidelines-Stroke data set, we identified 217 692 patients who presented to the hospital within 4.5 hours of AIS from April 2003 to March 2011, 106 113 before and 111 579 after the publication of ECASS III in September 2008. The proportion of patients with AIS who presented within 4.5 hours and were treated with tPA in the 3- to 4.5-hour window increased from 1.2% before ECASS III to 3.5% after (P<0.0001). The proportion of eligible patients with AIS presenting within 3.5 hours and treated within 4.5 hours increased from 19% (18 484/96 208) to 35% (26 888/77 309) (P<0.0001). ECASS III appeared to have no adverse affect on the treatment of patients who presented early because the proportion of eligible patients with AIS presenting within 2 hours and treated within 3 hours increased after ECASS III from 57% to 75% (P<0.0001), whereas median door-to-needle times in patients treated within 3 hours decreased from 79 to 74 minutes (P<0.0001).
  
  
  CONCLUSIONS
  Following publication of ECASS III, there has been a significant increase in the use of tPA between 3 and 4.5 hours without adversely affecting treatment of patients in the <3-hour window. However, there remains substantial opportunity to further improve treatment rates in the later time window.
authors.affiliation: Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA. messe@mail.med.upenn.edu
authors.forename: Steven R
authors.initials: SR
authors.lastname: Messé
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.forename: Lisa
authors.initials: L
authors.lastname: Kaltenbach
authors.forename: DaiWai M
authors.initials: DM
authors.lastname: Olson
authors.forename: Scott E
authors.initials: SE
authors.lastname: Kasner
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005060:Europe; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D007262:Infusions, Intravenous; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care / Q000592:standards* / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic / Q000592:standards*; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000592:standards* / Q000706:statistics & numerical data; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator