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The Cleveland Area Experience

Irene L. Katzan, MD; Anthony J. Furlan, MD; Lynne E. Lloyd, MBA; Jeffrey I. Frank, MD; Dwain L. Harper, DO; Judith A. Hinchey, MD; Jeffrey P. Hammel, MS; Annie Qu, PhD; Cathy A. Sila, MD

JAMA. 2000;283:1151-1158.

Context  Little is known regarding outcomes after intravenous tissue-type plasminogen activator (IV tPA) therapy for acute ischemic stroke outside a trial setting.

Objective  To assess the rate of IV tPA use, the incidence of symptomatic intracerebral hemorrhage (ICH), and in-hospital patient outcomes throughout a large urban community.

Design  Historical prospective cohort study conducted from July 1997 through June 1998.

Setting  Twenty-nine hospitals in the Cleveland, Ohio, metropolitan area.

Patients  A total of 3948 patients admitted to a study hospital with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification code 434 or 436).

Main Outcome Measures  Rate of IV tPA use and occurrence of symptomatic ICH among patients treated with tPA; proportion of patients receiving tPA whose treatment deviated from national guidelines; in-hospital mortality among patients receiving tPA compared with that among ischemic stroke patients not receiving tPA and with mortality predicted by a model.

Results  Seventy patients (1.8%) admitted with ischemic stroke received IV tPA. Of those, 11 patients (15.7%; 95% confidence interval [CI], 8.1%-26.4%) had a symptomatic ICH (of which 6 were fatal) and 50% (95% CI, 37.8%-62.2%) had deviations from national treatment guidelines. In-hospital mortality was significantly higher among patients treated with tPA (15.7%) compared with patients not receiving tPA (5.1%, P<.001) and compared with the model's prediction (7.9%; P<.006).

Conclusions  A small proportion of patients admitted with acute ischemic stroke in Cleveland received tPA; they experienced a high rate of ICH. Cleveland community experience with tPA for acute ischemic stroke may differ from that reported in clinical trials.

Author Affiliations: Cerebrovascular Center (Drs Katzan, Furlan, and Sila), Department of Biostatistics and Epidemiology (Mr Hammel), Cleveland Clinic Foundation and Quality Information Management Corporation, Cleveland, Ohio (Ms Lloyd and Dr Harper); Departments of Neurology and Surgery, University of Chicago, Chicago, Ill (Dr Frank); Neurology Department, University of Rochester, Rochester, NY (Dr Hinchey); and Department of Statistics, Oregon State University, Corvallis (Dr Qu).

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