Background: The benefits of intravenous tissue-type plasminogen activator (IV-Alteplase) in acute ischemic stroke (AIS) are time dependent. Current guidelines recommend a 60-minute door-to-needle (DTN) time for IV-Alteplase. Moreover, for every 15-minute reduction in treatment time, clinical outcomes are improved by an estimated 4%. In this study, we identified characteristics of patients with DTN times less than 30 minutes (i.e. “ultrafast DTN”).
Methods: Data obtained from the 26-hospital Providence Health and Services Get With the Guidelines stroke registry were used to identify patients with ultrafast DTN. IV-Alteplase-treated AIS patients over age 18 who were discharged from the hospital between 2009 and 2015 were included. A mixed effects logistic regression model with backwards elimination was used to identify which of the following variables were significant in predicting ultrafast DTN: year of discharge, age, gender, NIHSS score, weekend or evening admission, telestroke usage, hospital arrival time, mode of arrival (EMS vs private car), medical history of dyslipidemia, diabetes, atrial fibrillation, or hypertension, consult with a stroke neurologist, and the certification of the hospital. Parametric bootstrapped p-values, mean estimates and percentile confidence intervals were calculated.
Results: We identified 2,695 AIS patients who received IV-Alteplase between 2009 and 2015. Of those, only 108 (3.9%) had ultrafast DTN times. In the final bootstrap analysis, ultrafast DTN patients were more likely to be male (adjusted odds ratio (AOR) = 2.23; p<.001), ambulance arrivals (AOR = 4.76; p<.001), weekday arrivals (AOR = 1.89; p<.001), more severe cases (AOR per NIHSS point = 1.03; p=0.04), and more recently discharged (AOR per year = 1.34; p<.001).
Conclusion: In our large hospital network, we found that only a small proportion of AIS patients received ultrafast Alteplase administration, with males twice as likely as females to receive treatment in less than 30 minutes. This study highlights the necessity to further understand the role gender plays in treatment-related decisions.