title: Effect of the 2013 AHA/ASA guidelines on TPA use in acute ischemic stroke at Assaf Harofeh Medical Center in Israel.
abstract: BACKGROUND
  Use of TPA to treat patients with acute ischemic stroke was introduced in Assaf Harofeh Medical Center (AHMC) in Israel in November 2007 initially with strict adherence to the inclusion/exclusion criteria of the pivotal NINDS TPA studies published in 1995. The treatment window was expanded in 2010 to 4.5h following the results of ECASS-III. Application of the 2013 AHA/ASA Guidelines resulted in further expanded inclusion and relaxed exclusion criteria.
  
  
  METHODS
  A retrospective chart review was conducted of patients who received TPA at AHMC to evaluate the additional impact of applying the 2013 guidelines. Number of patients treated, outcomes at discharge, and safety were compared between two periods: May 2011-January 2013 (the 21months preceding the 2013 Guidelines); and February 2013-October 2014 (the 21months after publication of the 2013 Guidelines). Statistical analysis was done using z-tests for differences between proportions, and t-tests to compare means.
  
  
  RESULTS
  63 patients were treated during the immediate pre-2013 Guideline period (36/year, or approximately 5% of patients with ischemic stroke), and 105 during the post-2013 Guidelines period (60/year, approximately 8.3% of patients with ischemic stroke) (p<0.001). During the two periods, respectively: discharges home were 22(34%) and 55(52%) (p<0.05); facility discharges were 29(46%) and 33(31%); and inter-hospital transfers were 6(9%), and 11(10% of treated patients). Most transfers were for endovascular treatment. Total treatment-related symptomatic bleeds in the two periods, respectively, was: 4(6%) and 4(4%), and the number of in-hospital deaths was 6 (9%) and 6 (6%) (unchanged).
  
  
  CONCLUSIONS
  Application of the 2013 AHA/ASA Guidelines resulted in a 64% increase in the number of acute ischemic stroke patients treated with TPA at AHMC with no worsening of aggregate outcomes and no increase in bleeds or deaths.
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Itzhak
authors.initials: I
authors.lastname: Kimiagar
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Shani
authors.initials: S
authors.lastname: Kalmanovich-Avnery
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Ofer M
authors.initials: OM
authors.lastname: Gonen
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Zvika
authors.initials: Z
authors.lastname: Sacagiu
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Evelina
authors.initials: E
authors.lastname: Shevtzov
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Ronen
authors.initials: R
authors.lastname: Levite
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Jochay
authors.initials: J
authors.lastname: Weinstein
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Avigail
authors.initials: A
authors.lastname: Bartal
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Rina
authors.initials: R
authors.lastname: Aroesty
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Sarah
authors.initials: S
authors.lastname: Bhonkar
authors.affiliation: Department of Radiology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Sigal
authors.initials: S
authors.lastname: Tal
authors.affiliation: Department of Intensive Care, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Youval
authors.initials: Y
authors.lastname: Leonov
authors.affiliation: Department of Cardiac Intensive Care, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Alex
authors.initials: A
authors.lastname: Blatt
authors.affiliation: Department of Anesthesiology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Zoya
authors.initials: Z
authors.lastname: Haitov
authors.affiliation: Department of Emergency Medicine, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel.
authors.forename: Samuel
authors.initials: S
authors.lastname: Bar-Hayim
authors.affiliation: Department of Neurology, Assaf Harofeh Medical Center and Tel Aviv University Sackler Faculty of Medicine, Israel. Electronic address: carmon@asaf.health.gov.il.
authors.forename: Carmel
authors.initials: C
authors.lastname: Armon
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000150:complications*; D015510:Clinical Medicine / Q000592:standards*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006761:Hospitals / Q000592:standards; D006801:Humans; D007557:Israel / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000453:epidemiology / Q000209:etiology*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: AHA/ASA guidelines; Ischemic stroke; Outcomes; Safety; TPA