1. Use of SMART IV Thrombolysis Criteria at Community Hospitals is Safe
Sigrid B Sørensen, BSc2,4; Nobl Barazangi, MD, PhD1,2,3 ; Charlene Chen, MD1,2,3; Christine Wong, MD1,2,3; David Grosvenor, MS1,2,3
Jack Rose, MD1,2,3; Ann Bedenk, RN1; David C Tong, MD, FAAN, FAHA1,2,3
California Pacific Medical Center (CPMC) Comprehensive Stroke Care Center,1
CPMC Center for Stroke Research,2 CPMC Department of Neurosciences3, University of Copenhagen4
INTRODUCTION RESULTS
CONCLUSIONS
RESULTS
It is safe to apply SMART criteria to AIS patients who
receive tele-consultation for thrombolysis with IV rt-PA
before transfer to a large comprehensive stroke center.
Good functional outcome at discharge did not differ
between transfer and ED patients despite higher
admission stroke severity in the transfer population.
Although 91% of patients possessed at least 1
standard exclusion criterion, the sICH rate and
discharge outcomes were similar between ED and
transfer patients, and comparable to those reported in
randomized clinical trials.
REFERENCES
.
References:
1. NEJM 1995; 333:1581-87.
2. Ann. Emerg. Med. 2007; 50(2):99-107.
3. Presented at AAN Annual Meeting; April, 2010; Toronto, Canada.
4. Lancet 2010 May 15;375(9727):1695-703.
Disclosures:
N Barazangi: Genentech Speaker’s Bureau.
BACKGROUND
 Thrombolysis with IV rt-PA is the only approved medical treatment for
acute ischemic stroke1, but thrombolysis rates are very low (1-3%)2.
 The Simplified Management of Acute Stroke using Revised Treatment
(SMART) criteria expand thrombolysis rates by reducing exclusion criteria
for IV rt-PA. When applied to all acute ischemic stroke (AIS) patients at a
large comprehensive stroke center, the thrombolysis rate increased to 25-
30%, with low rates of symptomatic intracranial hemorrhage (sICH)3.
 Application of expanded inclusion criteria for IV rt-PA in a telemedicine
network may potentially have a big impact on overall treatment rates of AIS.
OBJECTIVE
To evaluate the safety of applying the SMART criteria to AIS patients at
community hospitals who receive consultation via telemedicine or telephone
prior to thrombolysis with IV rt-PA.
METHODS
 A retrospective study of all AIS patients treated with IV rt-PA using the
SMART criteria from 10/1/2008-8/1/2012 at the Emergency Department
(ED) at CPMC or community hospitals before transfer to CPMC. The
transferred patients all received a tele-consultation from CPMC before IV rt-
PA therapy.
The primary outcome was safety defined by rate of sICH. Secondary
outcomes were stroke severity at discharge (NIHSS), proportion with a good
functional outcome at discharge (mRS ≤ 1) and mortality.
RESULTS
Stroke severity at discharge (NIHSS)
A linear regression model controlling for demographics, medical history
and baseline functionality showed:
 Increasing age (p = 0.029), increasing NIHSS admit score (p < 0.001),
and non-white race (p = 0.019) were associated with worse stroke severity
at discharge.
IV rt-PA at a community hospital before transfer was not associated with
worse stroke severity at discharge (p = 0.535).
Number of exclusion criteria for IV rt-PA was not associated with worse
stroke severity at discharge (p = 0.415).
Table 1: Baseline characteristics
461 patients received IV rt-PA using the SMART criteria. 238 were
CPMC ED patients and 223 transferred. 973 AIS patients arrived
through the CPMC ED resulting in a thrombolysis rate of 24.5%.
EDs Transfers p-value
Age (mean) 73.44 69.51 0.006
Female (%) 51.3 54.7 0.513
Hispanic (%) 5.5 9.9 0.081
White (%) 71.4 83.4 0.349
Asian (%) 18.8 5.5 < 0.001
Black (%) 9.4 9.5 0.870
Afib (%) 42.8 43.7 0.924
Dyslipidemia (%) 55.1 63.4 0.084
CHF (%) 14.8 10.4 0.201
HTN (%) 71.6 78.4 0.103
DM (%) 22.9 27.2 0.326
Smoker (%) 10.6 21.1 0.003
MI, CAD, PVD (%) 30.1 19.7 0.012
Prior stroke/TIA (%) 24.6 24.5 1
Baseline mRS (mean) 0.54 0.35 0.001
Admit NIHSS (mean) 8.74 11.38 < 0.001
Figure 1: Frequency of standard exclusion criteria for IV rt-PA
91.2% of all patients had at least one standard exclusion criterion for IV rt-PA, mean
number of exclusion criteria was 2.07 (range 0-8). ED patients had a higher mean
number of exclusion criteria compared to transfers (2.51 vs. 1.74, p < 0.001).
195
154
76
62 60 60
35 32 29
18 15 15 14 13 12 11 7 5 4 4 3 3 0 0
37.6%
31.8%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Disch mRS ≤ 1
EDs
Transfers
Figure 2: Good functional outcome
Proportion of patients with a discharge
mRS ≤ 1 was the same (OR = 0.776
[0.514;1.171], p = 0.25).
(Average proportion in clinical trials is
34.8 %4)
Figure 3: Mortality
Transfers had a significantly higher
mortality rate (OR = 1.816 [1.034;3.192],
p = 0.048).
(Average mortality rate in clinical trials is
19.1%4)
10.9%
18.2%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Mortality
*
Primary outcome: Symptomatic Intracranial hemorrhage
There were 7 (3.3%) cases of sICH among ED patients and 9 (4.6%) cases
among transfers.
 sICH rate did not significantly differ between ED patients and transfers
(OR = 1.4 [0.513;3.846], p = 0.613).
 Meta-analysis of randomized clinical trials show an average sICH rate of 7.7%4.