Introduction and Hypothesis: Administration of intravenous tissue plasminogen activator (IV tPA) is currently the only FDA approved medical treatment for acute ischemic stroke. To improve outcomes the goal is to have reduced door to needle time (DTN) to IV tPA. Guidelines recommend obtaining coagulation tests prior to IV tPA, but new prescribing information suggest physicians may not need to wait for coagulation test results in patients not on anticoagulation therapy. We assessed the hypothesis if not waiting for these tests prior to IV tPA reduced the DTN time, without affecting the rate of symptomatic intracerebral hemorrhage (SICH).
Methods: The study is a retrospective analysis of prospectively collected data on acute ischemic stroke patients treated at a Joint Commission Certified Stroke Center. Based on differing physician practices, patients received IV tPA prior to results of screening coagulation tests or they received IV tPA after tests returned. Measures obtained from chart review included initial NIH stroke scale (NIHSS), DTN time, lab return time, abnormal lab results, and development of post IV tPA SICH (defined as ICH associated with an NIHSS increase ≥4).
Results: From January 2013 to May 2015, 136 patients received IV tPA. (Mean age ± SD = 65 ± 15 years, 53% male, 46% African American, 51% Caucasian, and 2% other, median NIHSS = 10, mean DTN ± SD = 65 ± 35 min). Group one, 102 patients, received IV tPA after test results were available (Mean age ± SD = 66 ± 15 years, 51% male, 50% African American, 48% Caucasian, and 2% other, median NIHSS = 10, mean DTN ± SD = 71 ± 34 min). Group two, 34 patients, received IV tPA prior to test results being available (Mean age ± SD = 64 ± 15 years, 59% male, 35% African American, 62% Caucasian, and 3% other, median NIHSS = 12, mean DTN ± SD = 46 ± 31 min). Group two had a significantly reduced DTN time (t test p<0.0002). No abnormal screening coagulation tests were found upon final review. There was no difference between in the rates of SICH (group one 4%, group two 6%, Fisher's exact test p>0.99).
Conclusions: Selection of appropriate patients to receive IV tPA without waiting for screening coagulation tests to be returned, significantly improved DTN time. There was no significant difference between the rates of SICH in the two groups.