title: Acute stroke reperfusion therapy trends in the expanded treatment window era.
abstract: BACKGROUND
  The American Heart Association/American Stroke Association (AHA/ASA) recommended an expansion of the time window for acute ischemic stroke (AIS) reperfusion with intravenous (IV) recombinant tissue plasminogen activator (rt-PA) from 3 to 4.5 hours after symptom onset. We examine rates of IV and intra-arterial (IA) reperfusion before and after the recommendations to track guideline adoption in community practice.
  
  
  METHODS
  Patients with AIS in the Paul Coverdell National Acute Stroke Registry spanning years 2007-2012 were identified. Trends in rates of IV rt-PA versus IA therapy were examined. Outcomes included symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, ability to ambulate at discharge, and discharge destination.
  
  
  RESULTS
  From 2007 to 2012, there were 182,235 AIS patients (median age, 72 years; 51.5% women) in the database at the time of analysis. AIS patients receiving IV rt-PA increased significantly from 3.7% in 2007 to 5.1% in 2012 in the ≤3 hours time window and from .2% in 2007 to 1.3% in 2012 in the 3-4.5 hours time window (P < .001 for both). There was also a significant increase in the rate of IA therapy between 2007 and 2012 (P < .001). There was a significant decrease in the rate of sICH among patients who received any reperfusion between 2007 and 2012.
  
  
  CONCLUSIONS
  There was a trend for increased utilization of IV rt-PA in the 0-3 hours and the 3-4.5 hours time windows, which began around the same time as the publication of AHA/ASA recommendations in 2009. This increase was associated with an increase in IA treatment rates along with a decrease in overall sICH rates for patients receiving any reperfusion.
authors.affiliation: Department of Neurology, University of Florida College of Medicine, Gainesville, Florida. Electronic address: ganesh785@gmail.com.
authors.forename: Ganesh
authors.initials: G
authors.lastname: Asaithambi
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Xin
authors.initials: X
authors.lastname: Tong
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Mary G
authors.initials: MG
authors.lastname: George
authors.affiliation: Minnesota Department of Health, St. Paul, Minnesota.
authors.forename: Albert W
authors.initials: AW
authors.lastname: Tsai
authors.affiliation: Minnesota Department of Health, St. Paul, Minnesota.
authors.forename: James M
authors.initials: JM
authors.lastname: Peacock
authors.affiliation: Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota.
authors.forename: Russell V
authors.initials: RV
authors.lastname: Luepker
authors.affiliation: Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota; Department of Neurology, University of Minnesota Medical School, Minneapolis, Minnesota.
authors.forename: Kamakshi
authors.initials: K
authors.lastname: Lakshminarayan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D017408:Guidelines as Topic; D017052:Hospital Mortality; D006801:Humans; D007261:Infusions, Intra-Arterial; D008297:Male; D008875:Middle Aged; D015424:Reperfusion / Q000639:trends*; D012959:Socioeconomic Factors; D020521:Stroke / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D015912:Thrombolytic Therapy; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Expanded time window; ischemic stroke; thrombolysis—trend analysis