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.

Racial Differences in Atrial Cardiopathy Phenotypes in Ischemic Stroke Patients.

OBJECTIVE: To test the hypothesis that thrombogenic atrial cardiopathy may be relevant to stroke-related racial disparities, we compared atrial cardiopathy phenotypes between Black versus White ischemic stroke patients. METHODS: We assessed markers of atrial cardiopathy in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of stroke incidence in a population of 1.3 million. We obtained ECGs and reports of echocardiograms performed during evaluation of stroke during the 2010/2015 study periods. Patients with atrial fibrillation (AF) or flutter (AFL) were excluded. Investigators blinded to patients' characteristics measured P-wave terminal force in ECG lead V1 (PTFV1), a marker of left atrial fibrosis and impaired inter-atrial conduction, and abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and atrial cardiopathy markers after adjustment for demographics, body mass index, and vascular comorbidities. RESULTS: Among 3,426 ischemic stroke cases in Black or White patients without AF/AFL, 2,391 had a left atrial diameter measurement (mean, 3.65 ±0.70 cm). Black race was associated with smaller left atrial diameter in unadjusted (ß coefficient, -0.11; 95% CI, -0.17 to -0.05) and adjusted (ß, -0.15; 95% CI, -0.21 to -0.09) models. PTFV1 measurements were available in 3,209 patients (mean, 3,434 ±2,525 µV*ms). Black race was associated with greater PTFV1 in unadjusted (ß, 1.59; 95% CI, 1.21 to 1.97) and adjusted (ß, 1.45; 95% CI, 1.00 to 1.80) models. CONCLUSIONS: We found systematic Black-White racial differences in left atrial structure and pathophysiology in a population-based sample of ischemic stroke patients. CLASSIFICATION OF EVIDENCE: This study provides class II evidence that the rate of atrial cardiopathy is greater among Black people with acute stroke compared to White people.