title: Analysis of tissue plasminogen activator eligibility by sex in the Greater Cincinnati/Northern Kentucky Stroke Study.
abstract: OBJECTIVE
  Sex differences in recombinant tissue-type plasminogen activator (r-tPA) administration are present in some populations. It is unknown whether this is because of eligibility differences or the modifiable exclusion criterion of severe hypertension. Our aim was to investigate sex differences in r-tPA eligibility, in individual exclusion criteria, and in the modifiable exclusion criterion, hypertension.
  
  
  METHODS
  We included all ischemic stroke patients ≥18 years among residents of the Greater Cincinnati/Northern Kentucky region who presented to 16-area emergency departments in 2005. Eligibility for r-tPA and individual exclusion criteria were determined using 2013 American Heart Association (AHA) and European Cooperative Acute Stroke Study (ECASS) III guidelines.
  
  
  RESULTS
  Of 1837 ischemic strokes, 58% were women, 24% were black. Mean age in years was 72.2 for women and 66.1 for men. Eligibility for r-tPA was similar by sex (6.8% men and 6.1% women; P=0.55), even after adjusting for age (7.0% and 5.9%; P=0.32). Similar proportions of women and men arrived beyond 3- and 4.5-hour time windows, but more women had severe hypertension. There were no sex differences in blood pressure treatment rates among those with severe hypertension (14.6% women and 20.8% men; P=0.21). More women were >80 years and had National Institutes of Health Stroke Scale (NIHSS) >25.
  
  
  CONCLUSIONS
  Within a large, biracial population, eligibility for r-tPA was similar by sex. Women were more likely to have the modifiable exclusion criterion of severe hypertension but were not more likely to be treated. Women were more likely to have 2 of the 5 ECASS III exclusion criteria. Undertreatment of hypertension in women is a potentially modifiable contributor to reported differences in r-tPA administration.
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.). Tracy_Madsen@brown.edu.
authors: Tracy E
authors: TE
authors: Madsen
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Jane C
authors: JC
authors: Khoury
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Kathleen A
authors: KA
authors: Alwell
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Charles J
authors: CJ
authors: Moomaw
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Brett M
authors: BM
authors: Kissela
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Felipe
authors: F
authors: De Los Rios La Rosa
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Daniel
authors: D
authors: Woo
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Opeolu
authors: O
authors: Adeoye
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Matthew L
authors: ML
authors: Flaherty
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Pooja
authors: P
authors: Khatri
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Simona
authors: S
authors: Ferioli
authors: From the Division of Women's Health in Emergency Care, Department of Emergency Medicine, The Alpert Medical School of Brown University, Rhode Island Hospital, Providence (T.E.M.); Neuroscience Institute (J.C.K., B.M.K., F.D.L.R.L.R., D.W., O.A., M.L.F., P.K., S.F., D.K.); Department of Neurology and Rehabilitation Medicine (K.A.A., C.J.M., B.M.K., F.D.L.R.L.R., D.W., M.L.F., P.K., S.F., D.K.) and Department of Emergency Medicine and Division of Neurocritical Care (O.A.), University of Cincinnati College of Medicine, OH; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K.); and Department of Neurology, Sanna Healthcare Network, Lima, Peru (F.D.L.R.L.R.).
authors: Dawn
authors: D
authors: Kleindorfer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy* / Q000453:epidemiology / Q000208:ethnology; D005006:Ethnicity; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000503:physiopathology; D007629:Kentucky; D008297:Male; D008875:Middle Aged; D009820:Ohio; D010358:Patient Participation; D012189:Retrospective Studies; D012737:Sex Factors; D020521:Stroke / Q000188:drug therapy* / Q000453:epidemiology / Q000208:ethnology; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: healthcare disparities; hypertension; sex characteristics; stroke; thrombolytic therapy
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