Abstract T P54: Generalized Application of SMART (Simplified Management of Acute Stroke using Revised Treatment) IV Thrombolysis Criteria in Acute Ischemic Stroke (AIS) Patients is Safe and Effective

Abstract

Introduction: Common IV rt-PA exclusion criteria may limit its use. The SMART criteria expand eligibility by reducing exclusions and can increase thrombolysis rates. However, applicability of SMART criteria to non-specialized centers is uncertain. We hypothesized that it is safe and efficacious to use SMART criteria in a wide range of hospital settings. Methods: Retrospective study of 539 consecutive acute ischemic stroke (AIS) patients receiving IV rt-PA using SMART criteria. Patients receiving IV rt-PA at a Comprehensive Stroke Center (CSC; n=267) versus Outlying Spoke Hospital (OSH; n=272) prior to transfer to the CSC were compared. There were 35 OSH (25-500+ beds) encompassing 120,000 sq miles in Northern California. The CSC neurologist was consulted by telephone (64%) or telemedicine (36%) in all cases. Primary outcomes were symptomatic intracranial hemorrhage (sICH) rate and favorable discharge outcome (mRS ≤ 1). Secondary measures were mortality and number of common rt-PA contraindications. Results: OSH patients were younger, had lower baseline mRS, and were clinically more severe. 90% had contraindications to rt-PA, the most common being mild symptoms (49%) and age ≥ 80 (37%). CSC had more contraindications than OSH patients (median (2(1-3) vs. 1(1-2), p < 0.001). Favorable outcome (45% vs. 37%; OR, 0.7[95% CI, 0.5-1.1]), sICH rate (2.6% vs. 5.1%; OR, 2.0[95% CI, 0.8-5.1]), and mortality (9% vs. 14%; OR, 1.6[95% CI, 0.95-2.8]) were not significantly different between groups. After baseline factor adjustment, OSH rt-PA treatment was not associated with increased sICH (adjusted OR, 0.6[95% CI, 0.2-2.0]) or reduced favorable outcome (adjusted OR, 0.97[95% CI, 0.5-1.8]). Conclusion: Generalized application of SMART criteria is safe and effective. Current rt-PA criteria may unnecessarily exclude patients from thrombolysis and need revision.