Sex-Based Analysis of Workflow and Outcomes in Acute Ischemic Stroke Patients Treated With Alteplase Versus Tenecteplase

BACKGROUND

Understanding sex differences in stroke care is important in reducing potential disparities. Our objective was to explore sex differences in workflow efficiency, treatment efficacy, and safety in the AcT trial (Alteplase Compared to Tenecteplase).

METHODS

AcT was a multicenter, registry-linked randomized noninferiority trial comparing tenecteplase (0.25 mg/kg) with alteplase (0.9 mg/kg) in acute ischemic stroke within 4.5 hours of onset. In this post hoc analysis, baseline characteristics, workflow times, successful reperfusion (extended Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracerebral hemorrhage, 90-day functional independence (modified Rankin Scale score, 0-1), and 90-day mortality were compared by sex. Mixed-effects regression analysis was used adjusting for age, stroke severity, and occlusion site for outcomes.

RESULTS

Of 1577 patients treated with intravenous thrombolysis (2019-2022), 755 (47.9%) were women. Women were older (median, 77 [68-86] years in women versus 70 [59-79] years in men) and had a higher proportion of severe strokes (National Institutes of Health Stroke Scale score >15; 32.4% versus 24.9%) and large vessel occlusions (28.7% versus 21.5%) compared with men. All workflow times were comparable between sexes. Women were less likely to achieve functional independence (31.7% versus 39.8%; unadjusted relative risk, 0.80 [95% CI, 0.70-0.91]) and had higher mortality (17.7% versus 13.3%; unadjusted relative risk, 1.33 [95% CI, 1.06-1.69]). Adjusted analysis showed no difference in outcomes between sexes.

CONCLUSIONS

Differences in prognostic factors of age, stroke severity, and occlusion site largely accounted for higher functional dependence and mortality in women. No sex disparities were apparent in workflow quality indicators. Given the integration of the AcT trial into clinical practice, these results provide reassurance that no major sex biases are apparent in acute stroke management throughout participating Canadian centers.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.

Mission thrombectomy 2020 (MT2020+) surveys of Caribbean stroke services: A call for action in our region

Stroke is the leading cause of death and adult-onset disability in the Caribbean region. Despite the tremendous advances in acute stroke care in the past 25 years, treatment in the Caribbean lags stroke standards of care. Mission Thrombectomy 2020+ (MT2020+) is a metrics based global campaign focused on increasing access to organized stroke care and mechanical thrombectomy. We conducted two consecutive online surveys across the MT2020+ Caribbean Region assessing access to thrombolytics, mechanical thrombectomy and stroke centers. The first survey - Mechanical Thrombectomy Access-Caribbean sub-study, allowed a comparison between global services and those in the MT2020+ Caribbean region. This survey provided a snapshot of the current state of stroke centers worldwide and confirmed lower available stroke resources in the MT2020+ Caribbean Region which has one certified stroke center, and 9 mechanical thrombectomy capable centers. The second survey - MT2020+ Caribbean Region infrastructure survey - was designed to determine the availability of stroke resources that are key components of stroke care in participating hospitals. Key infrastructural components such as 24/7 computerized tomographic scanners, access to thrombolytic therapy and access to mechanical thrombectomy capable centers were scarce. There were low volumes of mechanical thrombectomy performed in the Caribbean compared to other countries around the world. Limited resources and inadequate stroke infrastructure remains a major challenge in the Caribbean. We advocate for governmental support and investment, public and private partnerships and legislation to increase access and availability to acute stroke treatments to allow for equal access to care for all Caribbean citizens.

Abstract WP229: Prolonged Monitoring of Cardiac Rhythm With Wireless Cardiophone for Real Time Detection of Atrial Fibrillation After a Cerebral Ischemic Event (PEAACE II Study) The Edmonton Alberta Experience

Introduction: Atrial fibrillation (AF) is a leading cause of preventable stroke and can be prevented with anticoagulants. Prolonged cardiac monitoring can lead to better detection of AF. Real time cardiac monitoring may lead to earlier diagnosis and treatment.

Objective: Primary objective is to detect AF using wireless cardiophone for 14 days in stroke patients.

Secondary objective is to determine the reduction of time of AF diagnosis resulting in a prompt change in clinical management.

Method: This was a Cohort/Prospective study at the Univesity of Alberta Hospital. Patients ≥40 years of age (without known AF on ECG/Holter) who had an ischemic stroke or TIA within ≤90 days were eligible. The signals from cardiophone were analyzed in real time at Canadian cardiac center in Windsor, Ontario. The incidence and time of onset of AF and change in medical treatment (anti-coagulation) was recorded.

Results: Out of 120 patients, 118 completed monitoring for more than 48 hours. Twenty out of these 118 subjects (≈ 17 %) were shown positive for AF. When compared with the incidence of 5% reported in historical controls wearing 24 hour holter, the difference was significant (chi square p=0.004). Fourteen out of 20 AF subjects (70%)had AF duration of < 30 seconds, while 6/20 (30%) had a duration of >30 seconds. Mean time from onset of arrhythmia to report was ≈48 hours; shorter than the time for report with Holter (≈10 days in Alberta). Ninety percent of AF positive subjects were started on anti-coagulation therapies.

Conclusion: Prolonged cardiac monitoring for 14 days increased the detection of AF approximately 3 fold as compared to 24 hour Holter. Cardiophone device allowed feasible real time monitoring of heart rhythm and faster reporting time (within 48 hours) that lead to prompt change in medical treatment by the health care physician.

Abstract WP222: Comparison of Two Methods of External Prolonged Cardiac Monitoring for the Detection of Atrial Fibrillation: Cardiophone - satellite Real Time Device vs Sorin (Automated Software) for the Peaace Study

Introduction: Recent evidence has shown that prolonged cardiac monitoring is superior to 24 hour Holter for detection of atrial fibrillation (AF). We compared two methods of prolonged monitoring in patients with acute ischemic stroke and TIAs.

Objective: Comparison of the Cardiophone and Sorin monitor for detection of AF.

Method: In the first part of the study (PEAACE I; 2011-2013), we used the spiderflash (Sorin, Italy) for up to 21 days of monitoring. In the second part (PEAACE II; 2013-2015), Cardiophone with real time monitoring of the heart rhythm for 14 days was used.

Results: 102 patients in PEAACE I, (Mean age 72 +/-, 48.8% male) were compared to 120 patients in PEAACE II (Mean age 73 +/-, 70% male). Stroke type was “undetermined (cryptogenic) 92% and 91% in the two studies respectively. In PEAACE I, AF was detected in 43 out of 102 subjects (42%) (72% <30 seconds, 28% >30 seconds) with detection of 75% in the first week, 23% in the second, and 2% in the last week. In PEAACE II, 20 out of 120 subjects (17%) (70% <30 seconds, 30% >30 seconds) had AF, with 55% of detection in the first week, 45% in the second one (χ2 p=0.001). In PEAACE II, the results were available faster, within 2 days compared to 21 days in PEAACE I (χ2 p<0.0005). In PEAACE II, 90% of the patients received anticoagulation (93% of participants with A Fib <30 seconds, 83% with >30 seconds) compared to 77% in PEAACE I (68% with AF <30 seconds and 100% with AF >30 seconds) (χ2 p=0.021).

Conclusion: There were significant differences noted in the rates of detection with the two techniques. Real-time monitoring resulted in recording of fewer events but lead to earlier initiation of treatment. All patients with >30 seconds of AF were anticoagulated whereas fewer patients with less than 30 seconds of AF were anticoagulated.

Procedure for radiolabeling gizzerosine and basis for a radioimmunoassay

A method for the labeling of gizzerosine (GZ), a biogenic amine found in fish meal, is described. The labeling procedure with (125)I using a water-soluble Bolton-Hunter reagent and a mild water-insoluble oxidant (Iodogen) reagent is rapid and reproducible. The (125)I-GZ hapten was demonstrated to be immunologically active in a radioimmunoassay developed with polyclonal antibodies to GZ absorbed with a histamine-Sepharose column. The curves were linear in the range of 0.0001 and 0.1 microgram/mL. Samples of fish meal previously extracted of histamine with methanol and submitted to acid hydrolysis were contaminated with known amounts of GZ and submitted to the assay. The fish meal samples contaminated with GZ show a dose-response effect similar to the standard curve, and apparently the other component present in the sample did not interfere with the binding of the antibodies to (125)I-GZ. These data indicate the suitability of the radioimmunoassay to determine specifically GZ in fish meal.