The MAPSTROKE project: A computational strategy to improve access to acute stroke care.

BACKGROUND: Global access to acute stroke treatment is variable worldwide, with notable gaps in low and middle-income countries (LMIC), especially in rural areas. Ensuring a standardized method for pinpointing the existing regional coverage and proposing potential sites for new stroke centers is essential to change this scenario. AIMS: To create and apply computational strategies (CSs) to determine optimal locations for new acute stroke centers (ASCs), with a pilot application in nine Latin American regions/countries. METHODS: Hospitals treating acute ischemic stroke (AIS) with intravenous thrombolysis (IVT) and meeting the minimum infrastructure requirements per structured protocols were categorized as ASCs. Hospitals with emergency departments, noncontrast computed tomography (NCCT) scanners, and 24/7 laboratories were identified as potential acute stroke centers (PASCs). Hospital geolocation data were collected and mapped using the OpenStreetMap data set. A 45-min drive radius was considered the ideal coverage area for each hospital based on the drive speeds from the OpenRouteService database. Population data, including demographic density, were obtained from the Kontur Population data sets. The proposed CS assessed the population covered by ASCs and proposed new ASCs or artificial points (APs) settled in densely populated areas to achieve a target population coverage (TPC) of 95%. RESULTS: The observed coverage in the region presented significant disparities, ranging from 0% in the Bahamas to 73.92% in Trinidad and Tobago. No country/region reached the 95% TPC using only its current ASCs or PASCs, leading to the proposal of APs. For example, in Rio Grande do Sul, Brazil, the introduction of 132 new centers was suggested. Furthermore, it was observed that most ASCs were in major urban hubs or university hospitals, leaving rural areas largely underserved. CONCLUSIONS: The MAPSTROKE project has the potential to provide a systematic approach to identify areas with limited access to stroke centers and propose solutions for increasing access to AIS treatment. DATA ACCESS STATEMENT: Data used for this publication are available from the authors upon reasonable request.

Reperfusion therapy for acute ischemic stroke: where are we in 2023?

Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.

Nas últimas três décadas, o tratamento do AVC sofreu transformações significativas, impulsionadas principalmente pela introdução das terapias de reperfusão e pela organização dos serviços de AVC. Os pacientes que recebem tratamento em um serviço de AVC bem estruturado têm uma probabilidade muito maior de resultados favoráveis, diminuindo assim a incapacidade funcional e a mortalidade. Neste artigo, revisamos as evidências científicas para as terapias de reperfusão do AVC, incluindo trombólise e trombectomia e sua implementação no sistema público de saúde no Brasil.

Reperfusion therapy for acute ischemic stroke: where are we in 2023? / Terapia de reperfusão para o acidente vascular isquêmico agudo: onde estamos em 2023?

Abstract Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.

Resumo Nas últimas três décadas, o tratamento do AVC sofreu transformações significativas, impulsionadas principalmente pela introdução das terapias de reperfusão e pela organização dos serviços de AVC. Os pacientes que recebem tratamento em um serviço de AVC bem estruturado têm uma probabilidade muito maior de resultados favoráveis, diminuindo assim a incapacidade funcional e a mortalidade. Neste artigo, revisamos as evidências científicas para as terapias de reperfusão do AVC, incluindo trombólise e trombectomia e sua implementação no sistema público de saúde no Brasil.

Continuity and Change in Baseline Stroke Knowledge across the world: Second Wave of FAST Heroes campaign implementation.

OBJECTIVES: In this work we present the results of the implementation of a globally representative educational school-based stroke awareness programme, FAST (Face, Arm, Speech, Time) Heroes during the second year of education (wave 2). We aimed to observe changes in baseline stroke knowledge between wave 1 and wave 2, distinguish the more fine-grained effect of the campaign on society, and evaluate changes before and after the implementation of wave 2. MATERIALS AND METHODS: In wave 2, parents of school-aged children completed an online stroke preparedness questionnaire before (t1) and after (t2) programme implementation. Results between the time points were analyzed with descriptive statistics alongside changes in baseline knowledge between waves 1 and 2. RESULTS: 1,611 parents participated in wave 2. Parents increased their knowledge of three stroke symptoms from 69% to 87% (p<.001). Their knowledge of the designated emergency number rose from 75% (t1) to 88% (t2) (p<.001). A 17% increase in baseline knowledge occurred in stroke symptoms identified correctly between wave 1 (11 countries) and 2 (18 countries). CONCLUSIONS: Results support the precision and usability of the data collection approach in measuring the change in stroke knowledge between implementation waves. The increased baseline knowledge concerning stroke symptoms in wave 2 needs further examination.

Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil.

Background: The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods: Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results: A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion: Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.

FAST-ED scale for prehospital triage of large vessel occlusion: results in the field.

BACKGROUND: Acute ischemic stroke (AIS) is an extremely time-sensitive condition. The field triage of stroke patients should consider a careful balance between the best destination for the timely delivery of intravenous and/or endovascular reperfusion therapies. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale has been shown to have an accuracy comparable to that of the National Institutes of Health Stroke Scale (NIHSS). However, it has not been tested in the field. OBJECTIVE: To evaluate the accuracy of the FAST-ED scale in the detection of AIS due to large vessel occlusion (LVO) in the prehospital setting. METHODS: A cross-sectional study of consecutive prospective data collected from February 2017 to May 2019 in the city of Porto Alegre, state of Rio Grande do Sul, Southern Brazil, correlating the prehospital FAST-ED scale scores with the hospital diagnosis of LVO. Area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: In total, 74 patients were included in the analysis. As compared with the diagnosis of LVO upon hospital discharge, the prehospital FAST-ED scale applied by paramedics had a sensitivity of 80%, a specificity of 47.7%, a PPV of 51.1%, an NPV of 77.8%, and an AUC of 0.68 (95% confidence interval [95%CI]: 0.55-0.80). Among the patients with a final diagnosis of AIS, the accuracy was higher, with an AUC of 0.75 (95%CI: 0.60-0.89), a sensitivity of 80%, a specificity of 60%, a PPV of 80%, and an NPV of 60%. CONCLUSIONS: In the present study, the FAST-ED scale, which was applied by paramedics in the field, demonstrated moderate accuracy but high sensitivity and NPV, which are essential attributes for a triage scale. While larger studies are still needed, these findings further support the use of the FAST-ED in stroke triage.

ANTECEDENTES: O acidente vascular cerebral isquêmico (AVCI) é uma doença altamente dependente do tempo. A triagem de pacientes com AVCI na cena deve considerar um equilíbrio cuidadoso entre o melhor destino para a administração rápida de terapias de reperfusão intravenosas e/ou endovasculares. Já foi demonstrado que a escala de Avaliação de campo de triagem de AVC para destino de emergência (Field Assessment Stroke Triage for Emergency Destination, FAST-ED, em inglês) tem precisão comparável à da Escala de AVC dos Institutos Nacionais de Saúde dos Estados Unidos (National Institutes of Health Stroke Scale, NIHSS, em inglês). Entretanto, a FAST-ED não foi testada em campo. OBJETIVO: Avaliar a acurácia da escala FAST-ED na detecção de AVCI por oclusão de grande vaso (OGV) no contexto pré-hospitalar. MéTODOS: Estudo transversal de dados prospectivos consecutivos, coletados de fevereiro de 2017 a maio de 2019, em Porto Alegre, Rio Grande do Sul, Brasil, em que se correlacionam a pontuação pré-hospitalar na escala FAST-ED e o diagnóstico hospitalar de OGV. A área sob a curva (ASC), a sensibilidade, a especificidade, o valor preditivo positivo (VPP), e o valor preditivo negativo (VPN) foram calculados. RESULTADOS: Ao todo, 74 pacientes foram incluídos na análise. Comparada ao diagnóstico de OGV na alta hospitalar, a escala FAST-ED aplicada em campo por profissionais do pré-hospitalar teve sensibilidade de 80%, especificidade de 47,7%, VPP de 51,1%, VPN de 77,8%, e ASC de 0,68 (intervalo de confiança de 95% [IC95%]: 0,55­0,80). Entre pacientes com diagnóstico final de AVCI, a precisão foi mais alta, com ASC de 0,75 (IC95%: 0,60­0,89), sensibilidade de 80%, especificidade de 60%, VPP de 80%, e VPN de 60%. CONCLUSõES: Neste estudo, a escala FAST-ED, aplicada por profissionais do pré-hospitalar em campo, demonstrou precisão moderada, com alta sensibilidade e VPN, atributos essenciais para uma escala de triagem. Embora estudos com amostras maiores ainda sejam necessários, estes achados apoiam o uso da FAST-ED na triagem de AVCI.

FAST-ED scale for prehospital triage of large vessel occlusion: results in the field / Escala FAST-ED para a triagem pré-hospitalar de oclusão de grande vaso: resultados de campo

Abstract Background Acute ischemic stroke (AIS) is an extremely time-sensitive condition. The field triage of stroke patients should consider a careful balance between the best destination for the timely delivery of intravenous and/or endovascular reperfusion therapies. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale has been shown to have an accuracy comparable to that of the National Institutes of Health Stroke Scale (NIHSS). However, it has not been tested in the field. Objective To evaluate the accuracy of the FAST-ED scale in the detection of AIS due to large vessel occlusion (LVO) in the prehospital setting. Methods A cross-sectional study of consecutive prospective data collected from February 2017 to May 2019 in the city of Porto Alegre, state of Rio Grande do Sul, Southern Brazil, correlating the prehospital FAST-ED scale scores with the hospital diagnosis of LVO. Area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results In total, 74 patients were included in the analysis. As compared with the diagnosis of LVO upon hospital discharge, the prehospital FAST-ED scale applied by paramedics had a sensitivity of 80%, a specificity of 47.7%, a PPV of 51.1%, an NPV of 77.8%, and an AUC of 0.68 (95% confidence interval [95%CI]: 0.55-0.80). Among the patients with a final diagnosis of AIS, the accuracy was higher, with an AUC of 0.75 (95%CI: 0.60-0.89), a sensitivity of 80%, a specificity of 60%, a PPV of 80%, and an NPV of 60%. Conclusions In the present study, the FAST-ED scale, which was applied by paramedics in the field, demonstrated moderate accuracy but high sensitivity and NPV, which are essential attributes for a triage scale. While larger studies are still needed, these findings further support the use of the FAST-ED in stroke triage.

Resumo Antecedentes O acidente vascular cerebral isquêmico (AVCI) é uma doença altamente dependente do tempo. A triagem de pacientes com AVCI na cena deve considerar um equilíbrio cuidadoso entre o melhor destino para a administração rápida de terapias de reperfusão intravenosas e/ou endovasculares.Jáfoi demonstrado que a escala deAvaliação de campo de triagem de AVC para destino de emergência (Field Assessment Stroke Triage for Emergency Destination, FAST-ED, em inglês) tem precisão comparável à da Escala de AVC dos Institutos Nacionais de Saúde dos Estados Unidos (National Institutes of Health Stroke Scale, NIHSS, em inglês). Entretanto, a FAST-ED não foi testada em campo. Objetivo Avaliar a acurácia da escala FAST-ED na detecção de AVCI por oclusão de grande vaso (OGV) no contexto pré-hospitalar. Métodos Estudo transversal de dados prospectivos consecutivos, coletados de fevereiro de 2017 a maio de 2019, em Porto Alegre, Rio Grande do Sul, Brasil, em que se correlacionam a pontuação pré-hospitalar na escala FAST-ED e o diagnóstico hospitalar de OGV. A área sob a curva (ASC), a sensibilidade, a especificidade, o valor preditivo positivo (VPP), e o valor preditivo negativo (VPN) foram calculados. Resultados Ao todo, 74 pacientes foram incluídosnaanálise. Comparada aodiagnóstico de OGV na alta hospitalar, a escala FAST-ED aplicada em campo por profissionais do préhospitalar teve sensibilidadede80%, especificidadede47,7%, VPPde51,1%, VPN de 77,8%, e ASC de 0,68 (intervalo de confiança de 95% [IC95%]: 0,55-0,80). Entre pacientes com diagnóstico final de AVCI, a precisão foi mais alta, com ASC de 0,75 (IC95%: 0,60-0,89), sensibilidade de 80%, especificidade de 60%, VPP de 80%, e VPN de 60%. Conclusões Neste estudo, a escala FAST-ED, aplicada por profissionais do pré-hospitalar em campo, demonstrou precisão moderada, com alta sensibilidade e VPN, atributos essenciaispara umaescaladetriagem.Embora estudoscomamostras maiores ainda sejam necessários, estes achados apoiam o uso da FAST-ED na triagem de AVCI.

Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I.

The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.

Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I / Diretrizes da Academia Brasileira de Neurologia para reabilitação do acidente vascular cerebral: parte I

ABSTRACT The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.

RESUMO As Diretrizes Brasileiras para Reabilitação do AVC são fruto de um esforço conjunto do Departamento Científico de Reabilitação Neurológica da Academia Brasileira de Neurologia com o objetivo de orientar os profissionais envolvidos no processo de reabilitação para a redução da incapacidade funcional e aumento da autonomia dos indivíduos. Membros do grupo acima participaram de fóruns de discussão na web com pré-temas, seguidos de reuniões por videoconferência em que as controvérsias foram discutidas, levando a um consenso. Essas diretrizes, divididas em duas partes, focam as implicações de recentes ensaios clínicos, revisões sistemáticas e metanálises sobre reabilitação do AVC. O objetivo principal é servir de orientação a médicos, fisioterapeutas, fonoaudiólogos, terapeutas ocupacionais, enfermeiros, nutricionistas e demais profissionais envolvidos no cuidado pós-AVC. As recomendações e níveis de evidência foram adaptados de acordo com a literatura disponível atualmente. Aqui é apresentada a Parte I sobre tópicos de reabilitação na fase aguda, prevenção e tratamento de doenças e comorbidades frequentes após o AVC.

Disparities in Stroke Patient-Reported Outcomes Measurement Between Healthcare Systems in Brazil.

Introduction: Acute stroke interventions, such as stroke units and reperfusion therapy, have the potential to improve outcomes. However, there are many disparities in patient characteristics and access to the best stroke care. Thus, we aim to compare patient-reported outcome measures (PROMs) after stroke in two stroke centers representing the public and private healthcare systems in Brazil. Methods: PROMs through the International Consortium for Health Outcomes Measures (ICHOM) were assessed at 90 days after the stroke to compare two Brazilian hospitals in southern Brazil: a public university and a private stroke center, both with stroke protocols and stroke units. Results: When compared with the private setting (n = 165), patients from the public hospital (n = 175) were younger, had poorer control of risk factors, had more frequent previous strokes, and arrived with more severe strokes. Both hospitals had a similar percentage of IV thrombolysis treatment. Only 5 patients received mechanical thrombectomy (MT), all in the private hospital. Public hospital patients presented significantly worse outcomes at 3 months, including worse quality of life and functional dependence (60 vs. 48%, p = 0.03). Poor outcome, as measured by the mRS score, was significantly associated with older age, higher NIHSS score, and the presence of heart failure. However, the public practice was a strong predictor of any self-reported disability. Conclusion: Patients assisted at a good quality public stroke center with the same protocol used in the private hospital presented worse disability as measured by mRS and patient-reported outcome measures, with greater inability to communicate, dress, toilet, feed, and walk.

Regional and national differences in stroke thrombolysis use and disparities in pricing, treatment availability, and coverage.

BACKGROUND: Major disparities have been reported in recombinant tissue plasminogen activator (rtPA) availability among countries of different socioeconomic status. AIMS: To characterize variability of rtPA price, its availability, and its association with and impact on each country's health expenditure (HE) resources. METHODS: We conducted a global survey to obtain information on rtPA price (50 mg vial, 2020 US Dollars) and availability. Country-specific data, including low, lower middle (LMIC), upper middle (UMIC), and high-income country (HIC) classifications, and gross domestic product (GDP) and HE, both nominally and adjusted for purchasing power parity (PPP), were obtained from World Bank Open Data. To assess the impact of rtPA cost, we computed the rtPA price as percentage of per capita GDP and HE and examined its association with the country income classification. RESULTS: rtPA is approved and available in 109 countries. We received surveys from 59 countries: 27 (46%) HIC, 20 (34%) UMIC, and 12 (20%) LMIC. Although HIC have significantly higher per capita GDP and HE compared to UMIC and LMIC (p < 0.0001), the median price of rtPA is non-significantly higher in LMICs (USD 755, interquartile range, IQR (575-1300)) compared to UMICs (USD 544, IQR (400-815)) and HICs (USD 600, IQR (526-1000)). In LMIC, rtPA cost accounts for 217.4% (IQR, 27.1-340.6%) of PPP-adjusted per capita HE, compared to 17.6% (IQR (11.2-28.7%), p < 0.0001) for HICs. CONCLUSION: We documented significant variability in rtPA availability and price among countries. Relative costs are higher in lower income countries, exceeding the available HE. Concerted efforts to improve rtPA affordability in low-income settings are necessary.

Fighting Against Stroke in Latin America: A Joint Effort of Medical Professional Societies and Governments.

Introduction: Stroke is one of the leading causes of death in Latin America, a region with countless gaps to be addressed to decrease its burden. In 2018, at the first Latin American Stroke Ministerial Meeting, stroke physician and healthcare manager representatives from 13 countries signed the Declaration of Gramado with the priorities to improve the region, with the commitment to implement all evidence-based strategies for stroke care. The second meeting in March 2020 reviewed the achievements in 2 years and discussed new objectives. This paper will review the 2-year advances and future plans of the Latin American alliance for stroke. Method: In March 2020, a survey based on the Declaration of Gramado items was sent to the neurologists participants of the Stroke Ministerial Meetings. The results were confirmed with representatives of the Ministries of Health and leaders from the countries at the second Latin American Stroke Ministerial Meeting. Results: In 2 years, public stroke awareness initiatives increased from 25 to 75% of countries. All countries have started programs to encourage physical activity, and there has been an increase in the number of countries that implement, at least partially, strategies to identify and treat hypertension, diabetes, and lifestyle risk factors. Programs to identify and treat dyslipidemia and atrial fibrillation still remained poor. The number of stroke centers increased from 322 to 448, all of them providing intravenous thrombolysis, with an increase in countries with stroke units. All countries have mechanical thrombectomy, but mostly restricted to a few private hospitals. Pre-hospital organization remains limited. The utilization of telemedicine has increased but is restricted to a few hospitals and is not widely available throughout the country. Patients have late, if any, access to rehabilitation after hospital discharge. Conclusion: The initiative to collaborate, exchange experiences, and unite societies and governments to improve stroke care in Latin America has yielded good results. Important advances have been made in the region in terms of increasing the number of acute stroke care services, implementing reperfusion treatments and creating programs for the detection and treatment of risk factors. We hope that this approach can reduce inequalities in stroke care in Latin America and serves as a model for other under-resourced environments.

EXPRESS: COVID-19 AND STROKE â UNDERSTANDING THE RELATIONSHIP AND ADAPTING SERVICES. A GLOBAL WORLD STROKE ORGANISATION PERSPECTIVE.

A year ago the World Stroke Organisation (WSO) highlighted the enormous global impact of the COVID-19 pandemic on stroke care. In this review we consider a year later where we are now, what the future holds, and what the long term effects of the pandemic will be on stroke. Stroke occurs in about 1.4% of patients hospitalised with COVID-19 infection, who show an excess of large vessel occlusion and increased mortality. Despite this association, stroke presentations fell dramatically during the pandemic, although emerging data suggests that total stroke mortality may have risen with increased stroke deaths at home and in care homes. Strategies and guidelines have been developed to adapt stroke services worldwide, and protect healthcare workers. Adaptations include increasing use of telemedicine for all aspects of stroke care. The pandemic is exacerbating already marked global inequalities in stroke incidence and mortality. Lastly the pandemic has had a major impact on stroke research and funding, although it has also emphasised the importnace of large scale collaborative research initiatives.

Custo-efetividade de alteplase no tratamento de acidente vascular cerebral isquêmico até quatro horas e meia após início dos sintomas: perspectiva do Sistema Único de Saúde do Brasil (SUS) / Cost-effectiveness of alteplase for treatment of ischemic stroke up to four and a half hours after the onset of symptoms: a Brazilian Public Health System (SUS) perspective

Objetivo: Analisar o custo-efetividade da trombólise com alteplase no tratamento de acidente vascular isquêmico (AVCi) agudo em até 4,5 horas após início dos sintomas em comparação com tratamento clínico conservador, sob a perspectiva do Sistema Único de Saúde (SUS) no Brasil. Métodos: Construiu-se um modelo de Markov para simular o tratamento de AVCi agudo e suas consequências em curto e longo prazo. Foram conduzidas análises de custo-efetividade (anos de vida ganhos, AVG) e custo-utilidade (anos de vida ajustados pela qualidade de vida, QALY), considerando um horizonte temporal de tempo de vida. Parâmetros de eficácia e segurança foram obtidos em uma metanálise de dados individuais, considerando tratamento em até 3 horas e 3-4,5 horas. Os custos agudos e crônicos foram obtidos por análise secundária de dados de um hospital público brasileiro e expressos em reais (R$). Foram conduzidas análises de sensibilidade determinística e probabilística. Utilizou-se como limiar de disposição a pagar (LDP) 1 PIB (produto interno bruto) per capita para 2019 no Brasil (R$ 31.833,50). Resultados: O tratamento com alteplase vs. conservador resultou em incremento de 0,22 AVG, 0,32 QALY e R$ 4.320,12 em custo, com razão de custo-efetividade incremental (RCEI) estimada em R$ 19.996,43/AVG e R$ 13.383,64/QALY. Ambas as estimativas foram mais sensíveis a variações na efetividade e nos custos de tratamento agudo com alteplase. Para RCEI/AVG e RCEI/QALY, 70,7% e 93,1% das simulações na análise de sensibilidade probabilística estavam abaixo do LDP, respectivamente. Conclusões: O tratamento com alteplase até 4,5 horas após o início dos sintomas tem elevada probabilidade de ser custo-efetivo na perspectiva do SUS.

Objective: To assess the cost-effectiveness of thrombolysis with alteplase for the treatment of acute ischemic stroke up to 4.5 hours after the onset of symptoms as compared to conservative medical treatment from the perspective of the Brazilian Public Health System. Methods: A Markov model was used to simulate the treatment of acute stroke and the associated short- and long-term consequences. Cost-effectiveness (life-years gained, LYG) and cost-utility (quality-adjusted life years, QALY) analyses were performed considering a lifetime horizon. Efficacy and safety parameters were obtained from a meta-analysis of individual data, considering treatment within 3 hours and 3-4.5 hours after the onset of symptoms. Acute and chronic costs were derived from a secondary analysis of data obtained from a Brazilian public hospital and expressed in Brazilian reais (R$). Probabilistic and deterministic sensitivity analyses were performed. The willingness to pay threshold (WPT) was established as 1 GDP per capita for 2019 in Brazil (R$ 31,833.50). Results: Treatment with alteplase vs. conservative medical treatment was associated with an increase of 0.22 in LYG, 0.32 in QALY, and R$ 4,320.12 in cost. The incremental cost-effectiveness ratio (ICER) was estimated as R$ 19,996.43/LYG and R$ 13,383.64/QALY. Variations in effectiveness and costs of acute alteplase treatment had the greatest impact on sensitivity analyses. Considering ICER/LYG and ICER /QALY, 70.7% and 93.1% of the simulations in probabilistic sensitivity analysis were below the WPT, respectively. Conclusions: Treatment with alteplase up to 4.5 hours after the onset of symptoms has a high probability of being cost-effective from the perspective of the Brazilian Public Health System.

Association between electrocardiographic and echocardiographic atrial abnormalities and prognosis in cryptogenic stroke.

BACKGROUND AND PURPOSE: The role of atrial fibrillation in cryptogenic stroke (CS) is well known. However, the usefulness of left atrial (LA) electrical and morphological abnormalities to identify more disabling strokes in sinus rhythm patients is less studied. We evaluated the association between electrocardiographic P-wave abnormalities and echocardiographic LA measures with neurological disability in patients with cryptogenic stroke. METHODS: In a retrospective cohort, we included all consecutive hospitalized patients with cryptogenic stroke. Patients were classified according to modified Rankin scale at hospital discharge and at 3 months. LA abnormalities were identified by electrocardiographic (ECG) P-wave, axis and LA enlargement criteria, and by bidimensional echocardiograph through left atrial diameter and volume index. RESULTS: Among the 143 patients with CS (63.4 ± 14.2 years, 53% women), 70 patients were classified as non-disabling stroke (Rankin score < 2) and 73 patients as disabling stroke (Rankin score ≥ 2) at hospital discharge. On echocardiogram, more patients with disabling stroke presented with enlarged LA volume index (48% vs. 25%; p = 0.01). This difference remained significant after adjustment for age, gender, CHA2DS2-VASc and NIHSS scores (p = 0.02) and even when the LA volume index was analyzed as a continuous variable (p = 0.055). Also, enlarged LA volume index was more prevalent (52% vs. 25%; p = 0.03) among those with disabling stroke at 3 months after hospital discharge. Among ECG criteria, only the LA enlargement assessed by downward deflection was more prevalent in disabling stroke. CONCLUSION: Our study demonstrated an association between left atrial enlargement, assessed by downward deflection from ECG and volume index from echocardiogram, and more disabling cryptogenic strokes. This information could help to identify patients with poorer prognosis, or a subgroup where atrial cardiopathy may play a role in cardioembolic pathway.

Effect of a Quality Improvement Intervention on Adherence to Therapies for Patients With Acute Ischemic Stroke and Transient Ischemic Attack: A Cluster Randomized Clinical Trial.

IMPORTANCE: Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. OBJECTIVE: To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. DESIGN, SETTING AND PARTICIPANTS: This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. INTERVENTIONS: The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). RESULTS: A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). CONCLUSIONS AND RELEVANCE: A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02223273.