Effect of the 2013 AHA/ASA guidelines on TPA use in acute ischemic stroke at Assaf Harofeh Medical Center in Israel

Itzhak Kimiagar, Shani Kalmanovich-Avnery, Ofer M. Gonen, Zvika Sacagiu, Evelina Shevtzov, Ronen Levite, Jochay Weinstein, Avigail Bartal, Rina Aroesty, Sarah Bhonkar, Sigal Tal, Youval Leonov, Alex Blatt, Zoya Haitov, Samuel Bar-Hayim, Carmel Armon*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background Use of TPA to treat patients with acute ischemic stroke was introduced in Assaf Harofeh Medical Center (AHMC) in Israel in November 2007 initially with strict adherence to the inclusion/exclusion criteria of the pivotal NINDS TPA studies published in 1995. The treatment window was expanded in 2010 to 4.5 h following the results of ECASS-III. Application of the 2013 AHA/ASA Guidelines resulted in further expanded inclusion and relaxed exclusion criteria. Design/Methods A retrospective chart review was conducted of patients who received TPA at AHMC to evaluate the additional impact of applying the 2013 guidelines. Number of patients treated, outcomes at discharge, and safety were compared between two periods: May 2011–January 2013 (the 21 months preceding the 2013 Guidelines); and February 2013–October 2014 (the 21 months after publication of the 2013 Guidelines). Statistical analysis was done using z-tests for differences between proportions, and t-tests to compare means. Results 63 patients were treated during the immediate pre-2013 Guideline period (36/year, or approximately 5% of patients with ischemic stroke), and 105 during the post-2013 Guidelines period (60/year, approximately 8.3% of patients with ischemic stroke) (p < 0.001). During the two periods, respectively: discharges home were 22(34%) and 55(52%) (p < 0.05); facility discharges were 29(46%) and 33(31%); and inter-hospital transfers were 6(9%), and 11(10% of treated patients). Most transfers were for endovascular treatment. Total treatment-related symptomatic bleeds in the two periods, respectively, was: 4(6%) and 4(4%), and the number of in-hospital deaths was 6 (9%) and 6 (6%) (unchanged). Conclusions Application of the 2013 AHA/ASA Guidelines resulted in a 64% increase in the number of acute ischemic stroke patients treated with TPA at AHMC with no worsening of aggregate outcomes and no increase in bleeds or deaths.

Original languageEnglish
Pages (from-to)306-309
Number of pages4
JournalJournal of the Neurological Sciences
StatePublished - 15 Oct 2016


  • AHA/ASA guidelines
  • Ischemic stroke
  • Outcomes
  • Safety
  • TPA


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