Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes

Circulation. 2011 Feb 22;123(7):750-8. doi: 10.1161/CIRCULATIONAHA.110.974675. Epub 2011 Feb 10.


Background: The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and guidelines recommend an arrival to treatment initiation (door-to-needle) time of ≤60 minutes.

Methods and results: Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1082 hospitals participating in the Get With the Guidelines-Stroke Program from April 1, 2003, to September 30, 2009 were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. Among 25 504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60 minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 (P<0.0001). Despite similar stroke severity, in-hospital mortality was lower (adjusted odds ratio, 0.78; 95% confidence interval, 0.69 to 0.90; P<0.0003) and symptomatic intracranial hemorrhage was less frequent (4.7% versus 5.6%; P<0.0017) for patients with door-to-needle times ≤60 minutes compared with patients with door-to-needle times >60 minutes.

Conclusions: Fewer than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Disease
  • Aged
  • Aged, 80 and over
  • American Heart Association
  • Brain Ischemia / drug therapy*
  • Brain Ischemia / epidemiology
  • Emergency Medical Services / standards*
  • Female
  • Fibrinolytic Agents / administration & dosage
  • Guideline Adherence
  • Humans
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care / statistics & numerical data
  • Practice Guidelines as Topic
  • Risk Factors
  • Stroke / drug therapy*
  • Stroke / epidemiology
  • Time Factors
  • Tissue Plasminogen Activator / administration & dosage*
  • United States / epidemiology


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator