Thrombolytic Treatment Research Articles

Contemporary Management of Acute Ischemic Stroke.

In the past decade, adding mechanical thrombectomy (MT) of intracranial arterial occlusions to intravenous (IV) thrombolysis has revolutionized the treatment of acute ischemic stroke (AIS) by expanding the therapeutic window to 24h. Treatment decisions require establishing a high probability of AIS; confirming time since last known well (LKW); assessing severity of the neurological deficit; determining any contraindications to IV thrombolysis; and performing neuroimaging, usually noncontrast computed tomography (NCCT), to exclude intracerebral hemorrhage. If time since LKW is less than 4.5h, patients with disabling stroke without contraindications can proceed immediately to IV thrombolysis while the decision about MT is under way. For some patients, the MT decision can be made on the basis of clinical assessment, NCCT, and CT angiography showing a large vessel occlusion. Others may require additional neuroimaging. Patients who are not candidates for IV thrombolysis within 4.5h or MT should be immediately evaluated for eligibility for extended-window IV thrombolysis or early antiplatelet treatment.

Tenecteplase versus alteplase for acute stroke within 4·5 h of onset (ATTEST-2): a randomised, parallel group, open-label trial

Tenecteplase has potential benefits over alteplase, the standard agent for intravenous thrombolysis in acute ischaemic stroke, because it is administered as a single bolus and might have superior efficacy. The ATTEST-2 trial investigated whether tenecteplase was non-inferior or superior to alteplase within 4·5 h of onset. We undertook a prospective, randomised, parallel-group, open-label trial with masked endpoint evaluation in 39 UK stroke centres. Previously independent adults with acute ischaemic stroke, eligible for intravenous thrombolysis less than 4·5 h from last known well, were randomly assigned 1:1 to receive intravenous alteplase 0·9 mg/kg or tenecteplase 0·25 mg/kg, by use of a telephone-based interactive voice response system. The primary endpoint was the distribution of the day 90 modified Rankin Scale (mRS) score and was analysed using ordinal logistic regression in the modified intention-to-treat population. We tested the primary outcome for non-inferiority (odds ratio for tenecteplase vs alteplase non-inferiority limit of 0·75), and for superiority if non-inferiority was confirmed. Safety outcomes were mortality, symptomatic intracranial haemorrhage, radiological intracranial haemorrhage, and major extracranial bleeding. The trial was prospectively registered on ClinicalTrials.gov (NCT02814409). Between Jan 25, 2017, and May 30, 2023, 1858 patients were randomly assigned to a treatment group, of whom 1777 received thrombolytic treatment and were included in the modified intention-to-treat population (n=885 allocated tenecteplase and n=892 allocated alteplase). The mean age of participants was 70·4 (SD 12·9) years and median National Institutes of Health Stroke Scale was 7 (IQR 5-13) at baseline. Tenecteplase was non-inferior to alteplase for mRS score distribution at 90 days, but was not superior (odds ratio 1·07; 95% CI 0·90-1·27; p value for non-inferiority<0·0001; p=0·43 for superiority). 68 (8%) patients in the tenecteplase group compared with 75 (8%) patients in the alteplase group died, symptomatic intracerebral haemorrhage (defined by SITS-MOST criteria) occurred in 20 (2%) versus 15 (2%) patients, parenchymal haematoma type 2 occurred in 37 (4%) versus 26 (3%) patients, post-treatment intracranial bleed occurred in 94 (11%) versus 78 (9%) patients, significant extracranial haemorrhage occurred in 13 (1%) versus six (1%) patients, respectively, and angioedema occurred in six (1%) participants in both groups. Tenecteplase 0·25 mg/kg was non-inferior to 0·9 mg/kg alteplase within 4·5 h of symptom onset in acute ischaemic stroke. Easier administration of tenecteplase, especially in the context of interhospital transfers, indicates that tenecteplase should be preferred to alteplase for thrombolysis in acute ischaemic stroke. The ATTEST-2 population was large and representative of thrombolysis-eligible patients in the UK and, together with findings from other trials, provides robust evidence supporting the introduction of tenecteplase in preference to alteplase. The Stroke Association and British Heart Foundation.

Ultrasound-mediated cardiovascular thrombolysis: from Sonothrombolysis to Sonoperfusion.

The incidence of coronary artery disease has been increasing in recent years, with acute myocardial infarction as its most severe onset. The major aim for clinical treatment is to restore myocardial blood supply with the recanalization of coronary circulation as early as possible, while the still existed issue of microcirculation thromboembolism has become a serious obstacle. Thus, thrombus elimination in coronary microcirculation is crucial and essential to improve the treatment outcome of acute myocardial infarction. In recent years, from sonothrombolysis to sonoperfusion, ultrasound-mediated cardiovascular thrombolysis can effectively solve the problem of vascular thromboembolism, including microcirculation thromboembolism, and the treatment method is expected to obtain satisfied thrombolytic treatment effect with microthrombus elimination in coronary microvessels and function recovery of terminal microcirculation, which has potential clinical value for the establishment of novel treatment for coronary thromboembolism. Therefore, this paper reviews ultrasound-mediated cardiovascular thrombolysis including sonothrombolysis and sonoperfusion for the application exploration in the treatment of coronary artery thromboembolism, the mechanism of action, and its research progress.

A study on QT dispersion and thrombolytic therapy in acute myocardial infarction

Background: Myocardial infarction is a major manifestation of ischemic heart disease, a leading cause of death in developed nations and the third globally. QTc dispersion is an important marker of ventricular repolarization variations and arrhythmogenic risk. This study examines the effects of thrombolytic therapy on QTc dispersion in acute myocardial infarction Materials and methods: 88 patients admitted to Al Ameen Medical College Hospital, Vijayapur, for acute MI were included in the study. Over a period of 8±2 days, all patients underwent monitoring, with standard 12-lead ECGs conducted upon admission and before discharge. QT interval, QTc interval, and QT and QTc dispersion parameters were calculated from these ECGs. Results: Analysis revealed significant variations in QT parameters between patients treated and not treated with thrombolytic therapy. Patients receiving thrombolytic therapy exhibited greater reductions in QT parameters by day 8±2 compared to those without treatment. Additionally, anterior wall infarctions demonstrated significantly higher QT and QTc dispersions compared to inferior wall infarctions, with these differences being statistically significant. Conclusion: In the early stages of acute myocardial infarction, patients, especially those diagnosed with anterior myocardial infarction, exhibited significantly elevated QT and QTc dispersions. Thrombolytic treatment resulted in substantial reductions in these dispersions compared to untreated individuals. Typically peaking within the initial hours of the condition, these dispersions subsequently decline following successful thrombolysis, underscoring their significance in risk assessment for malignant ventricular tachyarrhythmias and reinforcing the efficacy of thrombolytic therapy

Understanding Endothelial Dysfunction and Its Role in Ischemic Stroke After the Outbreak of Recanalization Therapies.

Despite recent advances in treatment options, stroke remains a highly prevalent and devastating condition with significant socioeconomic impact. Recanalization therapies, including intravenous thrombolysis and endovascular treatments, have revolutionized stroke management and prognosis, providing a promising framework for exploring new therapeutic strategies. Endothelial dysfunction plays a critical role in the pathophysiology, progression, and prognosis of stroke. This review aims to synthesize the current evidence regarding the involvement of the nitric oxide (NO)/endothelium pathway in ischemic stroke, with a particular focus on aging, response to recanalization therapies, and therapeutic approaches. While significant progress has been made in recent years in understanding the relationship between endothelial dysfunction and stroke, many uncertainties persist, and although treatments targeting this pathway are promising, they have yet to demonstrate clear clinical benefits.

Efficacy and safety of reduced-dose and slow-infusion intravenous alteplase regimen in patients with acute pulmonary embolism at intermediate-high-risk

Abstract Background In patients with intermediate-high-risk (IHR) pulmonary embolism (PE), full-dose systemic thrombolytic treatment (STT) has been documented to lower the risk of hemodynamic decompensation and mortality, at the expense of an elevated risk of life-threatening bleeding. In this study, we aimed to evaluate the safety of reduced-dose STT regimen while maintaining effective reperfusion. Methods This single-center study comprised 124 retrospectively evaluated patients (female 58.9 % and mean age 55.4+15.8 years) diagnosed with acute PE at IHR status in accordance with European Society of Cardiology (ESC) 2019 acute PE guidelines in whom intravenous (i.v.) alteplase treatments were utilized. Patients fulfilling at least one of the following criteria have been included in the study: systolic blood pressure ≤ 110 mm Hg, heart rate &amp;gt; 100 bpm, SaO2 &amp;lt; 90 % on room air, respiratory rate &amp;gt; 20 breaths per minute, or serum lactate &amp;gt; 2 mmol/L. Exclusion criteria were any contraindication for STT and symptom onset &amp;gt; 14 days. Standard protocol for initial STT was i.v. infusion of alteplase of 25 mg over 4-6 hours. After completion of the infusion, a second STT in the same manner if one of the following criteria were present; heart rate &amp;gt; 100 bpm, SaO2 &amp;lt; 90 % or signs of organ hypoperfusion. Results Syncope and concomitant deep vein thrombosis were documented in 27.4 % and 49.2 % of patients, respectively. Baseline vital measures were as follows; heart rate: 112 +16.6 bpm, systolic blood pressure: 123+14.9 mm Hg, SaO2: 89 % (85-93), serum lactate 2.35 (1.6-2.9) mmol/L. Median alteplase dose and infusion duration were 50 (25-50) mg and 6 (4-10) hours, respectively. There were significant improvements in clinical parameters, pulmonary thrombus burden, pressure strain and right ventricular size and function as assessed by computed tomography and echocardiography (p&amp;lt; 0.001 for all). Minor and major bleeding events occurred in 3.2 % and 4.8 % of patients, respectively. One major bleed was due to cerebellar hemorrhage, but did not require surgery and patient was discharged without sequela. There were 6 (4.8 %) in-hospital deaths in which 2 were attributed to major hemorrhages and 4 due to hemodynamic decompensation. Conclusion In patients with acute IHR PE, reduced-dose and slow-infusion i.v. alteplase regimen seems to be a clinically relevant and safe reperfusion alternative to full-dose STT protocols associated with well-known major bleeding risks.

Thrombolysis versus primary percutaneous coronary intervention in patients with suspected ST-elevation myocardial infarction - a SWEDEHEART observational study

Abstract Background Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy in ST-elevation myocardial infarction (STEMI) patients provided time to reperfusion is ≤120 minutes. In patients presenting early with an estimated time to reperfusion &amp;gt;120 minutes, thrombolytic therapy should be considered according to European Society of Cardiology guidelines. However, there is a lack of contemporary data on patients treated with thrombolysis. Aims Our aim was to determine how often thrombolysis was administered in STEMI patients having an estimated time to reperfusion of &amp;gt;120 minutes and to study outcome differences between patients treated with thrombolysis compared to those treated with primary PCI. Methods We calculated transport times to nearest primary PCI centre using three-digit zip codes for each patient enrolled in the SWEDEHEART registry from 2008–2021 in the five geographic areas in Sweden routinely using thrombolysis and included those with &amp;gt;120 min estimated transportation time to reperfusion time. Patients without ST-elevations on prehospital ECG and ongoing chest pain as well as patients with left bundle branch block, pacemaker rhythm and patients with contraindications to thrombolysis were excluded. Patients were grouped by received reperfusion therapy with prehospital thrombolysis or no prehospital thrombolysis and studied with regard to 1- and 3-year mortality using Kaplan-Meier failure estimates and Cox regression adjusted for difference in baseline characteristics. Results A total of 1,840 patients were included of whom 1,381 (75.1%) received thrombolysis. A final diagnosis of STEMI was observed in 92.6% of patients receiving thrombolysis and 80.2% of patients treated with primary PCI. The median transport time estimate to a PCI centre was 153 minutes in both groups. Median time from onset of symptoms to reperfusion therapy was 131 minutes for the thrombolysis group and 255 minutes for the PCI group. Patients who received thrombolysis were on average 2 years younger and had fewer comorbidities such as diabetes, cancer and heart failure. Among patients treated with thrombolysis, a total of 42.7% of patients underwent rescue PCI. There was no significant difference in 365-day mortality (6.7% vs 11.8%, adjusted HR 0.84, 95% CI: 0.59-1.19, p=0.33) or 3-year mortality rates (10.3% vs 16.6%, adjusted HR 0.89, 95% CI: 0.66-1.19, p=0.44) between patients treated with thrombolysis and primary PCI groups. Conclusions In this population-based study of patients where primary PCI cannot be expeditiously used, we observed a commendable adherence rate of 75% to the ESC guidelines for thrombolysis treatment. Moreover, our findings revealed that the administration of thrombolysis was not associated with any discernible benefits or harm.Unadjusted and adjusted Cox-modelKaplan-Meier survival analysis

Twenty Years of Sustained Improvement in Quality of Care and Outcomes for Patients Hospitalized With Stroke or Transient Ischemic Attack: Data From The Get With The Guidelines-Stroke Program.

The Get With The Guidelines-Stroke program is a quality improvement initiative designed to enhance adherence to evidence-based stroke care. Since its inception in 2003, over 2800 hospitals in the United States have participated in the program. We examined patient characteristics, adherence to performance measures, and in-hospital outcomes in patients hospitalized for acute ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack in The Get With The Guidelines-Stroke hospitals from 2003 through 2022. We quantified temporal changes in performance measure adherence and clinical outcomes over time. Performance measure denominators consisted of patients who were eligible, excluding those with contraindications. Over the 20 years of the program, a total of 7837 849 stroke cases (median age 71 years, 51.0% female; 69.2% ischemic strokes, 3.9% SAHs, 11.5% ICHs, and 15.3% TIAs) were entered into the registry. Except for antithrombotics at discharge, in which the baseline performance was >92%, there was sustained improvement in all performance metrics regardless of type of cerebrovascular event (P<0.01 for all). In patients with acute ischemic stroke, large improvements were observed for anticoagulation for atrial fibrillation (55.7% in 2003 to 97.2% in 2022), smoking cessation counseling (44.7%-97.8%), dysphagia screening (53.8%-83.5%), thrombolytic treatment for patients arriving by 3.5 hours, treat by 4.5 hours (15.2%-92.9%), door-to-needle time within 60 minutes (19.0%-75.3%), and endovascular door-to-puncture time within 90 minutes (54.7%-62.8%). Similar improvements were also observed for measures relevant to patients with subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack. Multivariable analysis showed that there was a sustained increase in odds of receiving each performance measure over time, independent of patient and hospital characteristics for each type of cerebrovascular event. After risk adjustment, there were temporal trends that patients were less likely to be discharged to a skilled nursing facility, and, for ischemic stroke only, more likely to be discharged directly home. During the first 20 years, Get With The Guidelines-Stroke participation was associated with sustained improvement in evidence-based care and outcomes for patients with stroke and transient ischemic attack in the United States.

A telemedicine-enabled intravenous thrombolytic treatment pathway for patients with hyperacute non-arteritic central retinal artery occlusion

PurposeTo describe the visual acuity (VA) outcomes from a telemedicine-enabled pathway allowing for rapid diagnosis and administration of intravenous (IV) thrombolytic treatment for non-arteritic central retinal artery occlusion (naCRAO) within 4.5 hours (4.5 h) of visual loss. DesignRetrospective observational case series. MethodsSetting: A large managed healthcare consortium.Patient Population: Eighty-five patients with naCRAO and vision loss for less than 4.5 h presenting between 2021 and 2023. Thirty-five patients received IV thrombolytic therapy and 50 patients were closely observed.Intervention: A collaborative telemedicine-enabled pathway employing fundus photography was previously established by Ophthalmology, Emergency Medicine, and Stroke services to rapidly evaluate and manage patients presenting with acute painless monocular vision loss and allow for administration of IV tenecteplase (0.25 mg/kg) for eligible consenting patients diagnosed with naCRAO within 4.5 h. Retrospective chart review was conducted to collect data on demographics, vascular risk factors, clinical features, VA outcomes, and adverse events. Comparison was made between patients who received intravenous thrombolysis and those who were observed.Main Outcome Measures: Improvement in VA of at least 0.3 logarithm of the minimum angle of resolution (logMAR) and/or from 20/200 or worse to 20/100 or better. ResultsA greater percentage of patients in the treated group had VA improvement of ≥0.3 logMAR (54.3 % vs 28 %, p = .014), and a greater percentage of patients in the untreated group had VA worsening of ≥0.3 logMAR (30 % vs 5.7 %, p = .006). Twice the percentage of treated versus untreated patients had improved VA from 20/200 or worse to 20/100 or better, but this difference was not statistically significant (20 % vs 10 %, p = .192). There was a significantly shorter mean time to treatment for those patients who had VA improvement from 20/200 or worse to 20/100 or better compared to those who did not (118 versus 171 min, p = .031). Two patients experienced intracranial bleeding after IV thrombolysis. ConclusionsThe evaluation and treatment of hyperacute naCRAO is possible on a large scale via an integrated telemedicine-enabled approach utilizing fundus photography. The use of IV thrombolytic was associated with better VA outcomes compared to observation alone. Prospective randomized controlled trials are needed to confirm these findings and determine optimal management.

Streptokinase or Alteplase for Acute Limb Ischemia? A Meta-Analysis

Background: Acute limb ischemia (ALI) is a vascular emergency that necessitates prompt and effective treatment to restore blood flow and prevent limb loss. Thrombolytic therapy, particularly with agents like streptokinase and alteplase, plays a pivotal role in ALI management. This meta-analysis and systematic review aimed to compare the efficacy and safety of streptokinase and alteplase in treating ALI. Methods: A comprehensive search of PubMed, Embase, Science Direct, and the Cochrane Library databases was conducted up to August 13, 2024, to identify relevant studies. The inclusion criteria encompassed clinical trials involving patients diagnosed with ALI who received either streptokinase or alteplase as the initial thrombolytic treatment. The quality of the included studies was rigorously assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and the Methodological Index for Non-Randomized Studies (MINOR) criteria. A meta-analysis was performed using the Mantel-Haenszel random-effects model to calculate risk ratios (RRs) with their corresponding 95% confidence intervals (CIs). Results: The final analysis included 20 studies, encompassing both qualitative and quantitative assessments. A comparative analysis of streptokinase and alteplase for limb salvage at 30 days revealed a significant advantage in favor of alteplase, with a relative risk ratio (RR) of 0.78 (95% CI 0.69-0.88, I² = 0%). Furthermore, streptokinase was associated with a higher rate of primary amputation, with an RR of 2.54 (95% CI 1.50-4.32, I² = 0%) compared to alteplase. The use of streptokinase also correlated with a higher risk of complications, including major bleeding (RR 1.75, 95% CI 0.04-84.30, I² = 77%) and minor bleeding (RR 1.41, 95% CI 0.60-3.32, I² = 0%). Conclusion: The findings of this meta-analysis underscore the superior efficacy of alteplase in achieving limb salvage in ALI, coupled with a more favorable safety profile. The preferential use of alteplase in clinical practice is recommended, particularly in patients with severe ischemia. However, careful patient selection and close monitoring are crucial when streptokinase therapy is considered.

Hydrodynamic Cavitation‐Induced Thrombolysis on a Clot‐on‐a‐Chip Platform

Complications from thrombosis constitute a massive global burden for human health. Current treatment methods have limitations and can cause serious adverse effects. Hydrodynamic cavitation (HC) is a physical phenomenon where bubbles develop and collapse rapidly within a moving liquid due to sudden pressure changes. These collapsing bubbles provide high targeted energy which can be used in a controlled environment with the help of microfluidic devices. This study introduces a new clot‐on‐a‐chip (CoC) platform based on HC, evaluated for thrombolysis efficacy. The microfluidic device, paired with a polydimethylsiloxane (PDMS) microchip, generates cavitation bubbles at low upstream pressures (≤482 kPa), enabling microscale blood clot erosion. Different HC exposure conditions (varying pressure and duration) are assessed by changes in clot mass, diameter, and scanning electron microscopy (SEM). The largest mass reduction occurs at 482 kPa for 120 s, with a decrease of 6.1 ± 0.12 mg, while the most erosion in diameter of blood clots is obtained 482 kPa for 120 s with complete removal. SEM results show increasing damage to clot structure from less to more intense HC exposures. The CoC platform, at controlled pressures and durations, efficiently disrupts clot structure and offers a promising drug‐free alternative for thrombolysis treatment.

Percheron Artery Stroke and Reperfusive therapies: A systematic review and meta-analysis

Background and AimsPercheron Artery Stroke, affecting bilateral paramedian thalamic structures, accounts for 0.1–0.4 % of all acute ischemic strokes. Little is known about disability or mortality outcomes in patients receiving intravenous thrombolysis (IVT) or endovascular treatment (EVT), therefore a systematic review was carried out. MethodsA systematic search of Pubmed, Embase and Scopus databases for all kind of studies regarding Percheron Artery Stroke was performed. The review is registered in INPLASY (202410059). In total, 1895 papers were screened; 197 studies were included, consisting exclusively in case reports, retrospective series and conference abstracts. Data from 448 patients were analyzed in logistic regression. ResultsBoth IVT (ORIVT = 3.08; 95 % CI 1.4 – 6.7; p = 0.005) and EVT (OREVT = 5.77; 95 % CI 1.69 – 19.7; p = 0.005) were associated with reduced disability, as well as exclusive thalamic involvement (OR = 3.24; CI 2.1 – 5.1; p < 0.001) and higher Glasgow Coma Scale score (GCS) on admission (OR = 1.2; 95 % CI 1.12 – 1.28; p < 0.001). GCS (OR = 0.73, 95 % CI 0.63 – 0.82; p < 0.001) and exclusive thalamic involvement (OR = 0.36; 95 % CI 0.16 – 0.74; p = 0.005) were associated with lesser mortality, while IVT displayed a non-significant trend towards reduced mortality (ORIVT = 0.13; 95 % CI 0.01 – 1.04; p = 0.056). ConclusionThe present work, albeit summarizing data coming from low quality sources, suggests an association between both EVT/IVT and better outcomes in paramedian bilateral thalamic strokes.

Time Between Symptom Onset and Emergency Department Arrival and Thrombolytic Treatment Rates in Patients with Acute Ischemic Stroke

Time Between Symptom Onset and Emergency Department Arrival and Thrombolytic Treatment Rates in Patients with Acute Ischemic Stroke

Advancements in Imaging for the Diagnosis of Wake-up Stroke.

The concept of wake-up stroke (WUS) as a distinct subtype of acute ischaemic stroke, characterized by an uncertain onset time, traditionally resulted in the exclusion of patients from intravenous thrombolysis treatment. Advancements in neuroimaging have prompted a shift in the approach to intravenous thrombolysis treatment, moving away from a strict focus on the onset time window toward consideration of the tissue time window. This paradigm shift has expanded the opportunity for a larger cohort of patients with WUS to receive timely and effective treatment, ultimately leading to improved prognosis. This study reviews the WUS pathogenesis and the progress of various imaging diagnostic techniques to clarify the WUS onset time and select the optimal treatment plan.

Thrombolysis in wake-up stroke based on MRI mismatch

ObjectivesWake-up stroke (WUPS) patients can be selected to intravenous thrombolysis (IVT) treatment based on the Magnetic Resonance Imaging (MRI) mismatch concept. However, recent studies suggest the introduction of modified MRI mismatch criteria, allowing IVT in WUPS patients with a partial mismatch. Material and methodsWUPS patients treated with IVT in the NOR-TEST trial and consecutively thereafter at Stavanger University Hospital were included in this study. Patient selection for treatment was performed based on the clinical presentation and the MRI DWI/FLAIR mismatch criteria. MRI examinations were reassessed according to the modified DWI-FLAIR mismatch criteria, allowing partial mismatch. Improvement in NIHSS and mRS at 3 months were used to analyze clinical outcome, and the rate of intracranial hemorrhage (ICH) to analyze safety. Results78 WUPS patients were treated with IVT. Only 68 of these patients were independent pre-stroke and included in the clinical analysis. When reassessing the MRI examinations, 41 (60 %) were rated as DWI/ FLAIR mismatch, 14 (21 %) as partial mismatch and 13 (19 %) as match. The results show that the patient groups had a mRS score 0–1 at 3 months measured as primary outcome to respectively 27 (65.9 %), 11 (78.6 %) and 8 (61.5 %); (P = 0.629). The mismatch group showed the best clinical improvement (3-points NIHSS reduction, p = 0.005). No ICH was seen in any of the groups. ConclusionOur study extended the mismatch concept in clinical praxis to treat WUPS patients with partial mismatch, showing the best clinical outcome in the mismatch group.

Cost-effectiveness analysis of anticoagulation, percutaneous mechanical thrombectomy, and catheter-directed thrombolysis treatments for acute lower extremity deep venous thrombosis.

There is a lack of health economics studies on the treatment of acute lower extremity deep venous thrombosis to measure the benefits to patients. The purpose of this study was to evaluate the cost-effectiveness of anticoagulation (AC), percutaneous mechanical thrombectomy (PMT), and catheter-directed thrombolysis (CDT). The above 3 methods were selected according to the patient's treatment wishes. Related complications, clinical effective, occurrence of post-thrombotic syndrome (PTS) after 2 years, and total hospitalization costs of patients between the patients in these 3 treatment groups were analyzed. In the cost-effectiveness analysis, costs were expressed in monetary terms and the effect was expressed as the effective rate of clinical treatment. In addition, we used sensitivity analyses to validate the results. The effective rate of clinical treatment for the AC, CDT, and PMT groups were 44.23%, 86.84%, and 92.59%, respectively. No serious complications occurred in any of the treated patients. There was no significant difference in the incidence of PTS among the 3 groups during the follow-up period. After 12 months, compared with the AC group, there were statistically significant differences in moderate-severe reduction in PMT group and CDT group separately. At 24 months, the incidence of moderate-severe disease in PMT group was significantly lower than that in CDT group. All 3 treatment methods have good safety. Compared with AC therapy alone, both PMT and CDT therapy resulted in a higher clinical efficacy rate, reduced the severity of PTS within 2 years, and reduced the cost of PTS. From the perspective of the cost-effectiveness ratio, within a certain range of treatment efficacy, AC therapy alone incurs the lowest cost per 1% improvement in therapeutic effect. The cost-effectiveness results show that if decision-makers consider the standard for improving the cure rate of lower limb deep vein thrombosis by 1% to be lower than the ratio of incremental cost to effect, then AC therapy alone is chosen. If decision-makers consider the standard for improving the cure rate of lower limb deep vein thrombosis by 1% to be higher than the ratio of incremental cost to effect, then the choice is AC plus CDT treatment.

Predictors of One-year Mortality in Older Patients With Myocardial Infarction: Results of a Cohort Study

Objectives Little is known about the mortality rate of ST-segment elevation myocardial infarction (STEMI) in older people form low- and middle-income countries. Therefore, this study aims to investigate the predictors of one-year mortality in older people with STEMI in Kermanshah, Iran. Methods &amp; Materials This is a cohort study that was conducted on 421 older patients with STEMI admitted to Imam-Ali Hospital in Kermanshah from July 3, 2018, to December 21, 2019. Descriptive statistics were used to report the risk factors, and univariate and multiple Cox proportional-hazards model were used to investigate predictors of one-year mortality. Results The patients had a mean age of 73.51±6.73 years. The majority of them were male (67.5%), residents of Kermanshah (74.9%), and illiterate (60.8%). Reperfusion therapy was administered for 86.0% of patients (50.4% with percutaneous coronary intervention [PCI] and 30.4% with thrombolytic treatment). The follow-up period was 350.62 person-years. In one year, 76 patients (18.5%) died, of whom 12.4% had PCI, 16.1% thrombolytic treatment, and 0.38% no reperfusion therapy. Independent predictors of mortality were: No reperfusion therapy (hazard ratio [HR]: 2.42, 95% CI, 1.14%, 5.11%) and glomerular filtration rate (HR:0.97, 95% CI, 0.94%, 0.99%). Conclusion In this study, the older patients with STEMI treated by PCI had a lower one-year mortality rate. It is recommended to establish a comprehensive STEMI network to enhance timely reperfusion for these patients and improve their health literacy.

Prehospital computed tomography in a rural district for rapid diagnosis and treatment of stroke.

Early diagnosis and triage of patients with ischemic stroke is essential for rapid reperfusion therapy. The prehospital delay may be substantial and patients from rural districts often arrive at their local hospital too late for disability-preventing thrombolytic therapy due to prolonged transport times. Hallingdal District Medical Centre (HDMC) is located in a rural area of Norway and is equipped with a computed tomography (CT) scanner. We established emergency pathways of CT imaging and thrombolytic treatment of patients with acute ischemic stroke at HDMC. During office hours these pathways were managed by a radiographer and a general physician supported by videoconference from the Primary Stroke Centre. Outside office hours we remotely controlled the CT exam and supported telestroke guided paramedics handling and examining the patients. With a primary aim of demonstrating the feasibility of this de novo concept we enrolled patients in the period 2017-2021 into a comparative cohort observational study. We compared patients treated at HDMC (the Rural CT group) to patients from two other rural regions in Norway with similar distances to their local hospital but without access to a rural CT scanner (the Reference group). A total of 86 patients were included in the Rural CT group (mean age 74, 52% male, 43% stroke mimics), and 69 patients were included in the Reference group (mean age 70, 42% male, 28% stroke mimics). Median time from onset of symptoms to completed CT examination was 93 min in the Rural CT group as compared to 240 min in the Reference group (p < 0.05). In patients receiving intravenous thrombolysis time from onset of symptoms to treatment was median 124 min in the Rural CT group and 213 min in the Reference group, p < 0.05. The frequency of thrombolysis for ischemic stroke did not significantly differ between the two groups. Combining prehospital rural CT examination with telestroke guided diagnosis and thrombolytic treatment by paramedics may facilitate earlier initiation of thrombolysis for patients with ischemic stroke.

Study on the public awareness of stroke risk factors, symptoms, treatment and rehabilitation: A community based cross sectional survey from a tertiary referral centre in South India

Background: The incidence of Non communicable diseases (NCDs) including stroke is increasing in India over the past few years. Thrombolysis therapy has revolutionized management of acute ischemic stroke. In spite of such recent advances in stroke therapy, the public remains uninformed about stroke symptoms and management. Objective: To assess the public awareness of stroke risk factors, symptoms, treatment and rehabilitation measures. Methods: The study was a community-based cross-sectional study, designed as an online survey. The tool used for the survey was a semi-structured online questionnaire. Results: Regarding the risk factors of stroke, of the participants, 41 (14.8%) were aware of valvular heart diseases, 18 (6.5%) of lack of exercise, 238 (85.9%) of dyslipedemia, 236 (85.2%) of hypertension, 222 (80.1%) of smoking, and 154 (55.6%) of diabetes. Regarding symptoms of stroke, of the participants, 209 (75.5%) were aware of loss of balance, 240 (86.6%) of speech abnormalities, 261 (94.2%) of facial weakness, and 234 (84.5%) of weakness. Conclusion: Efforts should be made to educate the public regarding uncommon symptoms of stroke, thrombolysis treatment and rehabilitation measures, so that people make beneficial health care decisions in stroke management.

Evaluating Thrombolysis Rates and Emergency Department Time Targets in Acute Ischemic Stroke: Need for Personalized Medicine.

In the era of personalized medicine, standard protocols regarding the management of acute ischemic stroke (AIS) focus on time targets alone without tailoring the protocol to the specific patient and hospital characteristics to increase IV thrombolysis rates and improve outcomes for these patients by considering organizational differences and patient-related factors that influence adherence to target times at the emergency department level. With this in mind, we evaluate the effect of achieving ED time targets from standard protocol and patient-related risk factors on the intravenous (IV) thrombolysis rate in patients with AIS in the therapeutic window. For our research, we enrolled people who arrived at the ED with signs of recent AIS with an onset of less than 4.5 h. Initially, 355 patients were included in the study, but through careful screening, only 258 were considered eligible to participate. Of the final group of 258 patients, only 46 received intravenous thrombolysis treatment. In our study, when we are analyzing ED times in patients admitted with stroke symptoms in the therapeutic window, we found statistically significantly decreased ED times for patients that performed IV thrombolysis compared to patients not performing as follows: a median of 100 min in onset-to-ED door time (p < 0.001), a door-to-physician time (ED doctor) of 4 min (p = 0.009), door-to-blood-samples of 5 min (p = 0.026), a door-to-CT time of 15.5 min (p = 0.009), and door-to-CT results of 37 min (p < 0.001). In addition, patients who received intravenous thrombolysis were found to be significantly older (p < 0.001), with lower height and weight (p < 0.001 for both) and lower Glasgow Coma Scale (GCS) scores (9 ± 4.94 vs. 13.85 ± 2.41, p < 0.001). The logistic regression analysis indicated that the onset-to-ED time (p < 0.001) and the door-to-physician time (p = 0.014) for emergency medicine physicians are significant predictors of the likelihood of administering thrombolysis. By analyzing the impact of comorbidities, we observed that dyslipidemia, chronic arterial hypertension, and diabetes mellitus are significant predictive factors for performing IV thrombolysis (the presence of dyslipidemia and diabetes mellitus are predictive factors for performing IV thrombolysis, while the presence of arterial hypertension is not). The ED time targets that significantly influenced IV thrombolysis in our study were the onset-to-ED door time and the time it takes for the ED doctor to assess the AIS patient (door-to-physician time). The IV thrombolysis rate for these patients was 17.83%, lower than expected despite achieving most ED time targets, with the presence of chronic arterial hypertension as a significant predictive patient-related factor for not performing it. Even though our reported hospital's thrombolysis rate is favorable compared to international reports, there is always room for improvement. Based on our study results, it is necessary that new protocols to customized standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right. Based on our study results, it is necessary that new protocols customize standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right.