Abstract 116: Unmet Need In Acute Ischemic Stroke Patients Not Treated With Alteplase

Abstract

Introduction: Early administration of intravenous tissue plasminogen activator (IV alteplase) improves functional outcomes in patients with acute ischemic stroke (AIS), yet many patients are not treated with IV alteplase. There is a need to understand the reasons for non-treatment and the short- and long-term outcomes in this patient population. Methods: We analyzed patients ≥65 years old with a primary diagnosis of AIS presenting within 24 hours of time last known well (LKW) but not treated with IV alteplase from 1,630 Get With The Guidelines-Stroke Hospitals in the United States between January 2016 and December 2016. We report clinical characteristics, reasons for withholding treatment, in-hospital mortality, 90-day and 1-year outcomes including Medicare costs, stratified by time from LKW to presentation (≤4.5 hours, >4.5-6 hours and >6-24 hours). Results: Of 39,760 patients (median age 80 [25 th -75 th quartiles: 73-87], 56.7% female), 19,391 (48.8%) presented within 4.5 hours of LKW. In those with documented reasons for withholding IV alteplase, the most common reasons were rapid improvement of symptoms (3,985/14,782, 27.0%) and mild symptoms (3,791/14,782, 25.6%). In 1,100 out of 1,174 (93.7%) patients presenting in the >3.0-4.5-hour time window, the most common reason for not treating was a delay in patient arrival. The most common discharge location for those presenting ≤4.5 hours since LKW was home (8,660/19,391, 44.7%). The 90-day mortality and re-admission rates were 18.9% and 23.0% in those presenting ≤4.5 hours since LKW, 19.0% and 22.2% in those presenting between 4.5 and 6 hours, and 19.1% and 23.2% in those presenting between 6 and 24 hours. Median 90-day total in-hospital costs remained relatively high at $9,471 (IQR: $5,622-$21,356) in patients presenting ≤4.5 hours since LKW. Conclusions: Patients within the GWTG-Stroke registry not treated with IV alteplase have a high risk of re-admission and mortality and have high total in-hospital and post-discharge costs. This study may inform future efforts to address the unmet need to improve the scope of IV alteplase delivery along with other aspects of AIS care and, consequently, outcomes in this patient population.