In acute ischemic stroke
More eligible patients could benefit through improved patient selection and protocol adherence¹

• Eligibility
• Protocol adherence

• *
• Percentages rounded to nearest whole number.

Activase (t-PA) treatment begins with proper patient selection

• Despite the proven benefits of Activase (t-PA), 1 survey found that only about 27% of patients arriving within 3 hours of symptom onset received treatment¹
  • – Various other studies show that 72% to 87% of eligible patients may go untreated^1-3
• Major reasons why patients who arrived within the 3-hour window were excluded from treatment¹:
  • – Clinical improvement (18.2%)
  • – Symptoms too mild (13.1%)
• Documentation of onset times and eligibility is also critical²
• Treatment is not recommended after 3 hours of acute ischemic stroke symptom onset or in patients with minor neurologic deficit or with rapidly improving symptoms

Stroke centers increase treatment and improve patient outcomes^4-7

Reducing pre- and in-hospital response times and using appropriate resources increased the number of eligible patients who received Activase (t-PA)²

A study of primary stroke center recommendations found 7 criteria associated with Activase (t-PA) use⁷†:

• Continuing medical education‡
• Written care protocols‡
• Organized emergency department‡
• Integrated emergency medical services‡
• Neuroimaging services
• Stroke unit
• Acute stroke teams

• ^†
• Brain Attack Coalition criteria and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommendations.

• ^‡
• Associated with significantly increased Activase (t-PA) use.

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Patient selection and protocol adherence may improve stroke outcomes^5,8-10

Be proactive

• Apply established standards of patient selection and follow proven treatment protocols
• Review eligibility criteria in specific patient populations

Click on the links below to view information about Activase (t-PA) use in specific types of stroke patients.

• Patient eligibility — elderly stroke patients
• Patient eligibility — severe stroke patients
• More eligible patients could benefit
• Protocol adherence improves stroke outcomes

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Patient eligibility — elderly stroke patients
Activase (t-PA) may benefit older stroke patients^11-13

• ^§
• Assessed by scores on Modified Rankin Scale (MRS) and National Institutes of Health Stroke Scale (NIHSS) at hospital discharge. Percentages do not always total 100 because of rounding.¹²

The risk of symptomatic intracranial hemorrhage (SICH) in patients >77 years of age may be increased and should be weighed against anticipated benefits.

• Age should not necessarily preclude Activase (t-PA) treatment in eligible patients. The potential benefits and risks in older patients are comparable with those achieved in younger patients^11-13:
  • – Similar proportions of favorable outcomes at discharge seen in patients >80 years of age (37%)∥ vs patients <80 years of age (30%) (P=0.52)¹²
  • – 54% (P>0.99) of patients in both groups had NIHSS scores¶ <5 and 43% (P>0.99) showed marked improvement¹²

• ^∥
• Represented by an MRS score of 0 to 1.

• ^¶
• Represented by an MRS score of 0 to 5.

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Patient eligibility — severe stroke patients
Activase (t-PA) may benefit severe stroke patients^14,15

NIHSS=National Institutes of Health Stroke Scale.

•   ^#
• Possible range of NIHSS scores=0 to 42; a higher score reflects more severe disability.

• **
• Favorable outcome=Modified Rankin Scale score of 0 or 1.

Activase (t-PA)–treated patients presenting with severe neurologic deficit (eg, NIHSS score >22) have an increased risk of SICH within the first 36 hours.

At 1 year:

• Greater percentages of patients on Activase (t-PA) had favorable outcomes vs placebo, regardless of the severity of baseline NIHSS scores (post-hoc analysis of the 6- and 12-month data from the NINDS study)¹⁴

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More eligible patients could benefit
FACT: 72% to 87% of eligible patients may go untreated despite the proven benefits of Activase (t-PA)^1-3

Along with in-hospital stroke protocols, quality improvement (QI) programs are critical to delivering Activase (t-PA) to all eligible patients.

• Review all patient exclusions
• Evaluate hospital processes to streamline delays in patient assessment and evaluation
• Promote a better understanding of patient eligibility requirements

Studies about quality improvement and patient exclusion in the use of Activase (t-PA) in acute ischemic stroke:

Barber PA, Zhang J, Demchuk AM, et al. Why are stroke patients excluded from TPA therapy? Neurology. 2001;56:1015-1020.

Deng YZ, Reeves MJ, Jacobs BS, et al. IV tissue plasminogen activator use in acute stroke. Neurology. 2006;66:306-312.

Cocho D, Belvís R, Martí-Fàbregas J, et al. Reasons for exclusion from thrombolytic therapy following acute ischemic stroke. Neurology. 2005;64:719-720.

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Protocol adherence improves stroke outcomes
Quality improvement led to decreased protocol violations, improved safety, and increased Activase (t-PA) usage⁵

Adapted from Katzan IL et al. Stroke. 2003;34:799.

• ^††
• One tertiary care center and 8 community hospitals.

• ^‡‡
• Three specified protocol deviations included: t-PA treatment beyond 3 hours (n=7), antiplatelet agents or anticoagulant given within 24 hours (n=1), and deviations from blood pressure guidelines (n=3). t-PA administration was among all admitted ischemic stroke patients.

After implementing a quality improvement (QI) program to enhance stroke outcomes, the Cleveland Clinic Health System found evidence of improved outcomes⁵:

• Rate of protocol deviations lowered from 33% to 17%
• Rate of SICH lowered from 13.4% to 6.4%
• Increase from 1.8% to 2.7% in rate of Activase (t-PA) use among all admitted patients with ischemic stroke

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