Conversion From Intravenous Alteplase to Tenecteplase for Treatment of Acute Ischemic Stroke Across a Large Community Hospital Health System.

BACKGROUND: Recent evidence suggests tenecteplase at an intravenous dose of 0.25 mg/kg is as safe and efficacious as intravenous alteplase standard dose and demonstrates a more favorable pharmacokinetic profile for treatment of acute ischemic stroke. OBJECTIVE: The purpose was to compare the safety and efficacy of alteplase versus tenecteplase for the treatment of acute ischemic stroke at a large community hospital health system following conversion in the preferred formulary thrombolytic. METHODS: Prior to converting, medication safety and operationalization analyses were conducted. A multicenter, retrospective medical record review was performed for patients who received alteplase 6 months prior to formulary thrombolytic conversion and for tenecteplase 6 months post-conversion for the treatment of acute ischemic stroke. Primary outcomes included the rate of symptomatic intracranial and extracranial hemorrhage complications. Secondary outcomes included door-to-needle time, reduction in National Institute Health Stroke Scale at 24 hours and at discharge, order-to-administration time, and thrombolytic errors. The rates of hemorrhage were compared using binomial regression. RESULTS: Of the 287 patients reviewed, 115 received alteplase and 172 received tenecteplase. Symptomatic intracranial hemorrhagic complications occurred in 1 patient (1%) who received alteplase compared with 3 patients (2%) who received tenecteplase (P = 0.9). There was no statistical difference in rates of symptomatic intracranial or extracranial hemorrhagic complications. CONCLUSION AND RELEVANCE: Conversion from alteplase to tenecteplase can be safely and effectively achieved at a large community hospital health system with differing levels of stroke certification. There were also additional cost savings and practical advantages including workflow benefits.

The Effect of a County Prehospital FAST-ED Initiative on Endovascular Treatment Times.

BACKGROUND: Acute stroke outcomes depend on timely reperfusion. In 3/2017, local EMS agencies implemented a prehospital triage algorithm with hospital bypass and field activation of the neurointerventional team using the Field Assessment Stroke Triage for Emergency Destination (FAST-ED). A score ≥4 bypasses to a comprehensive stroke center (CSC) and a score ≥6 also has the interventional team field activated off-hours. AIM: We analyzed effects of this initiative on volume, acute stroke transfers, treatment times, and outcomes and determined the tool's ability to predict large vessel occlusion. METHODS: Stroke cases brought to our center by EMS during 3/2016-2/2018 were analyzed, which included one year before and after FAST-ED implementation. Treatment times were compared on- vs. off-hours and to those with field activation. RESULTS: Of 1153 patients, 761 (67%) were coded as stroke and 235 (20%) underwent reperfusion. Age, sex, race/ethnicity, stroke severity, length of stay, door-to-needle, and 90-d mRS were comparable between periods. Scale compliance was 85%. Concordance rate of ±1 between EMS and calculated score was 53%. Compared to the previous year, door-to-puncture (DTP) improved by 17 min (p < 0.01) overall, 25 min (p < 0.001) off-hours, and 33 min (p < 0.05) with field activation. A cutoff of 4 vs. 6 would have led to 140% increase in field activations but only 36% increase in procedures. CONCLUSIONS: This prehospital initiative led to faster DTP by up to 33 min. The highest impact was off-hours with field activation. Only 1/3 of activations led to endovascular treatment. FAST-ED≥6 appears to be appropriate for field activation.