title: Generalized Safety and Efficacy of Simplified Intravenous Thrombolysis Treatment (SMART) Criteria in Acute Ischemic Stroke: The MULTI SMART Study.
abstract: BACKGROUND
  Common intravenous recombinant tissue plasminogen activator (IV rt-PA) exclusion criteria may substantially limit the use of thrombolysis. Preliminary data have shown that the SMART (Simplified Management of Acute stroke using Revised Treatment) criteria greatly expand patient eligibility by reducing thrombolysis exclusions, but they have not been assessed on a large scale. We evaluated the safety and efficacy of general adoption of SMART thrombolysis criteria to a large regional stroke network.
  
  
  METHODS
  Retrospective analysis of consecutive patients who received IV thrombolysis within a regional stroke network was performed. Patients were divided into those receiving thrombolysis locally versus at an outside hospital. The primary outcome was modified Rankin Scale score (≤1) at discharge and the main safety outcome was symptomatic intracranial hemorrhage (sICH) rate.
  
  
  RESULTS
  There were 539 consecutive patients, and 50.5% received thrombolysis at an outside facility. Ninety percent of the patients possessed common conventional IV rt-PA contraindications. There were no significant differences between local and network treated patients in favorable outcome (45.4% versus 37.4%; odds ratio [OR], .72; P > .09), mortality (9% versus 14%; OR, 1.6; P > .07), or sICH rate (2.6% versus 5.1%; OR, 2.0; P = .13). Multivariate analysis showed no association between receiving IV rt-PA at an outlying spoke hospital and higher rate of sICH or worse outcome at discharge.
  
  
  CONCLUSIONS
  Generalized application of SMART criteria is safe and effective. Widespread application of these criteria could substantially increase the proportion of patients who might qualify for treatment.
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; University of Copenhagen, Copenhagen, Denmark.
authors.forename: Sigrid B
authors.initials: SB
authors.lastname: Sørensen
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; CPMC Department of Neurosciences.
authors.forename: Nobl
authors.initials: N
authors.lastname: Barazangi
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; CPMC Department of Neurosciences.
authors.forename: Charlene
authors.initials: C
authors.lastname: Chen
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; CPMC Department of Neurosciences.
authors.forename: Christine
authors.initials: C
authors.lastname: Wong
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; Palo Alto Medical Foundation, Palo Alto, California.
authors.forename: David
authors.initials: D
authors.lastname: Grosvenor
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; CPMC Department of Neurosciences.
authors.forename: Jack
authors.initials: J
authors.lastname: Rose
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; CPMC Department of Neurosciences.
authors.forename: Ann
authors.initials: A
authors.lastname: Bedenk
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; CPMC Department of Neurosciences.
authors.forename: Megan
authors.initials: M
authors.lastname: Morrow
authors.affiliation: CPMC Department of Emergency Medicine, San Francisco, California.
authors.forename: Dan
authors.initials: D
authors.lastname: McDermott
authors.affiliation: University of Copenhagen, Copenhagen, Denmark; Cardiovascular Section, Department of Medicine, Hvidovre Hospital, Hvidovre, Denmark; Center for Functional and Diagnostic Imaging and Research, Hvidovre Hospital, Hvidovre, Denmark.
authors.forename: Jens D
authors.initials: JD
authors.lastname: Hove
authors.affiliation: CPMC Center for Stroke Research, San Francisco, California; California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center, San Francisco, California; CPMC Department of Neurosciences. Electronic address: tongdc@sutterhealth.org.
authors.forename: David C
authors.initials: DC
authors.lastname: Tong
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000175:diagnosis / Q000188:drug therapy*; D002140:California; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D004185:Disability Evaluation; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007262:Infusions, Intravenous; D020300:Intracranial Hemorrhages / Q000139:chemically induced; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D011237:Predictive Value of Tests; D011994:Recombinant Proteins / Q000008:administration & dosage; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator
keywords: Ischemic stroke; stroke management; telemedicine; thrombolysis