Background: Timely prehospital care is the first link in the stroke chain of survival, yet large-scale data on how specific EMS intervals affect acute stroke treatment are limited. We evaluated the association between delays in prehospital care and receipt of IV thrombolysis, endovascular therapy (EVT), and anticoagulation (AC) reversal in a national stroke registry. Methods: This was a retrospective cohort analysis of EMS-transported stroke cases from the American Heart Association Get With The Guidelines-Stroke National Registry (January 1, 2018 to August 31, 2023). Delays in EMS care were defined per guidelines or median values: dispatch to scene arrival (>8 min); scene time (>15 min); scene departure to ED arrival (>15 min); and total prehospital interval (> 40 min). Outcomes included receipt of IV thrombolysis and EVT for patients with acute ischemic stroke (AIS), and AC reversal for patients with hemorrhagic stroke. Logistic regression models with generalized estimating equations (GEE) for intervention-eligible patients controlled for patient demographics, insurance status, past medical history, and hospital characteristics. Race-based interaction terms were tested for effect modification. Results: There were 261,689 AIS patients with last known well ≤4 hours (IV thrombolysis-eligible), 333,527 patients with LKW time ≤24 hours (EVT-eligible), and 13,306 patients with hemorrhagic stroke. Delays in all prehospital intervals significantly reduced the odds of receiving thrombolysis, while delays in scene time, scene departure to ED arrival, and total prehospital interval significantly reduced the odds of EVT; delays were not associated with AC reversal (Figure 1). Longer scene time was associated with longer door-to-needle and door-to-groin times (Figure 2a-b). There was a significant interaction effect by race on the association between prehospital scene time delays and receipt of thrombolysis (p<.001) and EVT (p=.004), with effect sizes varying across racial subgroups (Figure 3). Discussion: Prehospital delays are strongly associated with reduced odds of receiving proven acute ischemic stroke treatments, including thrombolysis and EVT. Targeted strategies to minimize these delays are critical for optimizing stroke care.

BACKGROUND:Rural residents have been experiencing higher stroke mortality than urban residents, and the gap has widened. Disparity in postacute care after stroke may increase the rural-urban gaps of mortality and disability. We aimed to examine whether rural patients with stroke receive the same postacute care and achieve comparable outcomes to urban patients. METHODS:We conducted a cohort study of Medicare beneficiaries aged ≥65 years treated in the Get With The Guidelines-Stroke participating hospitals for acute ischemic stroke during 2017 to 2022. We used restricted mean home-time to compare 1-year home-time among patients discharged from rural versus urban hospitals and the Cox proportional hazards model for all-cause mortality and readmission, adjusting for patient and hospital characteristics. RESULTS:The analysis included 29 734 patients treated in rural hospitals and 478 122 in urban hospitals, with a mean age of 79 years, and 55.5% were women. Compared with patients in urban hospitals, patients in rural hospitals were less commonly discharged to inpatient rehabilitation facilities (20.1% versus 25.1%; adjusted odds ratio, 0.76 [95% CI, 0.69-0.84]) and more frequently to skilled nursing facilities (24.5% versus 20.9%; adjusted odds ratio, 1.21 [95% CI, 1.11-1.32]). Compared with urban patients, rural patients had 1.8 fewer days of home-time (95% CI, -3.2 to -0.3) overall; rural patients discharged to skilled nursing facilities had 5.7 fewer days of home-time (95% CI, -9.0 to -2.3), and those discharged home had 2.2 fewer days of home-time (95% CI, -3.7 to -0.7). Rural patients overall had comparable all-cause mortality with urban patients (adjusted hazard ratio, 1.01 [95% CI, 0.98-1.05]) and lower all-cause readmission (adjusted hazard ratio, 0.92 [95% CI, 0.90-0.95]). However, rural patients who were discharged home had higher all-cause mortality than urban patients (adjusted hazard ratio, 1.11 [95% CI, 1.05-1.17]). CONCLUSIONS:Compared with urban patients, rural patients with stroke had less inpatient rehabilitation facility and more skilled nursing facility utilization, less home-time, but similar mortality. Further efforts are needed to ensure equitable postacute care in rural areas.

Importance:Tenecteplase is an alternative to alteplase for intravenous thrombolysis in acute ischemic stroke given its simplified administration and comparable safety and efficacy. However, its impact on workflow metrics that may affect clinical outcomes, such as door-to-needle and door-in-door-out times, has not been well-characterized. Objective:To compare door-to-needle and door-in-door-out times between tenecteplase-treated and alteplase-treated patients with acute ischemic stroke in US hospitals. Design, Setting, and Participants:This cohort study used data from the American Heart Association's Get With The Guidelines-Stroke registry between July 1, 2020, and June 30, 2022. The analysis included adult patients with ischemic stroke who received intravenous thrombolysis. Data analysis was conducted from August to November 2023. Exposure:Tenecteplase or alteplase treatment in a consecutive series of patients with ischemic stroke. Main Outcomes and Measures:Primary outcomes were door-to-needle time among patients who arrived directly to the reporting hospital and door-in-door-out time among those transferred after thrombolytic administration. Secondary outcomes were door-to-puncture and other endovascular workflow metrics among patients treated with thrombectomy after thrombolysis. Generalized linear mixed models were used to assess the association between thrombolytic treatment and workflow time intervals outcomes. Results:Of 133 228 thrombolysis-treated patients (mean [SD] age, 68.3 [14.8] years; 64 173 female [48.2%]; median [IQR] National Institutes of Health Stroke Scale score, 7 [3-14]), 13 988 (10.5%) received tenecteplase, and 119 240 (89.5%) received alteplase. The mean (SD) door-to-needle time was significantly shorter with tenecteplase vs alteplase (47.0 [26.8] vs 52.7 [28.0] minutes; adjusted mean difference, -3.13 minutes; 95% CI, -3.84 to -2.42 minutes). Door-to-needle time 30 minutes or less occurred more frequently with tenecteplase than with alteplase (2955 of 9893 patients [29.9%] vs 14 781 of 72 539 patients [20.4%]; adjusted odds ratio [aOR], 1.34; 95% CI, 1.25 to 1.44), as did door-to-needle time 45 minutes or less (5766 of 9893 patients [58.3%] vs 35 238 of 72 539 patients [48.6%]; aOR, 1.24; 95% CI, 1.17 to 1.32) and 60 minutes or less (7670 of 9893 patients [77.5%] vs 51 282 of 72 539 patients [70.7%]; aOR, 1.25; 95% CI, 1.17 to 1.33). Among transferred patients likely eligible for mechanical thrombectomy, mean (SD) door-in-door-out times were shorter for tenecteplase vs alteplase (108.3 [31.6] vs 114.1 [32.0] minutes; adjusted mean difference, -5.94 minutes; 95% CI, -9.10 to -2.77 minutes). Among patients receiving thrombectomy, shorter times were observed in the tenecteplase group for door-to-arterial puncture, door-to-device deployment, and door-to-reperfusion. Hospitals that transitioned to tenecteplase during the study period had faster door-to-needle time times after vs before the switch (mean [SD], 51.1 [12.1] vs 52.7 [10.8] minutes; adjusted mean difference, -1.52 minutes; 95% CI, -2.88 to -0.15 minutes). Conclusions and Relevance:In this analysis of a large nationwide registry, tenecteplase was associated with faster door-to-needle and door-in-door-out times than alteplase. These workflow advantages provide support for broader use of tenecteplase for stroke thrombolysis.

Introduction: There is minimal real-world data on whether stroke process quality metrics differ for intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS) and if they have changed over time. Identifying and addressing these differences may inform targeted quality improvement initiatives to optimize acute stroke outcomes. Methods: AIS and ICH patients admitted to Get With The Guidelines-Stroke participating hospitals from Jan 1, 2015 to June 30, 2024 who arrived by emergency medical services (EMS) were included. Outcomes included prehospital-based process metrics (EMS prenotification, last known well (LKW) and stroke symptom onset to ED arrival time) and ED-based metrics (door to ED physician assessment; door to stroke team activation; door to stroke team arrival; door to first stroke severity score; door to initial brain imaging order; and door to initial brain imaging report). Generalized estimating equations were used in logistic and linear regression models to evaluate the association between stroke type (ICH vs AIS) and outcomes, with sequential adjustment for patient demographics, medical history and presenting factors, and hospital characteristics. Temporal trends of prehospital care metrics were examined. Results: 195,659 patients (N=31,464 with ICH; N=164,195 with AIS) from 195 hospitals were included. The median (IQR) NIHSS was 14 (6-23) for ICH vs 6 (2-13) for AIS (absolute standardized difference 69.4). ICH (vs AIS) was associated with higher odds of door to ED physician assessment ≤10 mins after adjusting for patient demographics (aOR 1.08, 95% CI 1.02, 1.14). This association reversed after adding adjustment for medical history and presenting factors (including NIHSS), and hospital characteristics (aOR 0.94, 95% CI 0.89, 0.99). A similar pattern was observed for door to initial brain imaging order ≤20 mins (demographic-adjusted: aOR 1.09, 95% CI 1.02, 1.16; fully adjusted with medical history and hospital characteristics: aOR 0.91, 95% CI 0.85, 0.97). Median LKW to arrival time increased by 32.5% for AIS (151 to 200 min; p < .0001) and 34.3% (108 min to 145 min; p < .0001) for ICH over the study period. Discussion: From 2015 to 2024, patients with ICH were less likely to achieve timely ED-based process metrics compared to patients with AIS, despite faster presentation to the ED. Future quality improvement initiatives should target these differences to ensure all patients with stroke receive time-sensitive care.

BACKGROUND & AIMS:Hepatic steatosis has been associated with major adverse cardiovascular events independently of other cardiovascular risk factors and the severity of coronary artery disease. Nevertheless, the relationship between hepatic steatosis, coronary plaque composition, and major adverse cardiovascular events remains unclear. METHODS:A central core laboratory analyzed Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) participants randomized to the computed tomography arm. Hepatic steatosis was assessed on noncontrast computed tomography using standard hepatic and splenic attenuation methods. Coronary computed tomography angiography was used to quantify total, calcified, noncalcified, and low-attenuation plaque volume and burden (% vessel volume). Multivariable regression and mediation analyses assessed relationships between hepatic steatosis, plaque components, and major adverse cardiovascular events (death, myocardial infarction, unstable angina hospitalization). The median follow-up was 25 months (interquartile range, 18-33 months). RESULTS:Among 3637 patients (age, 60.6 ± 8.2 years; 51.4% female), 25.5% had hepatic steatosis and were slightly younger, more often male, had more cardiovascular risk factors, and had a higher rate of major adverse cardiovascular events (4.1% vs 2.5%) (all P < .05). After adjustment for clinical risk factors, hepatic steatosis was associated with greater noncalcified plaque burden (β, 0.15%; 95% confidence interval, 0.04-0.27; P = .008). Hepatic steatosis was associated with increased risk of major adverse cardiovascular events independent of atherosclerotic cardiovascular disease risk score, obesity, obstructive stenosis, and noncalcified plaque burden (adjusted hazard ratio, 1.69; 95% confidence interval, 1.12-2.54; P = .012), whereas noncalcified plaque burden mediated 11% of the association between hepatic steatosis and major adverse cardiovascular events. CONCLUSIONS:Hepatic steatosis was associated with greater noncalcified plaque burden and increased risk of major adverse cardiovascular events, with noncalcified plaque burden accounting for a portion of this association, suggesting a link between hepatic steatosis and vulnerable coronary atherosclerosis. These findings support integrated cardiometabolic risk assessment in patients undergoing coronary computed tomography angiography. CLINICALTRIALS:gov number, NCT01174550.

Background Left bundle branch (LBB) area pacing (LBBAP) is increasingly used for patients with a ventricular pacing indication. Multi-center studies analyzing predominantly lumenless leads have suggested a learning curve for LBBAP; analogous data on stylet-driven leads (SDLs) is lacking. Objective To assess the relationship between site volume and procedural outcomes and complications utilizing the INGEVITY+ SDL for LBBAP. Methods A secondary analysis of the INSIGHT-LBBA multi-site registry was performed, with retrospective data collected across 8 US sites performing LBBAP with INGEVITY+ SDLs between 2020-2023. Outcomes included LBBAP and LBB capture success rates, pacing parameters, fluoroscopy time, number of leads used, and lead-related complications. Outcomes were assessed using a generalized estimated equation based on consecutive implants. A sensitivity analysis was performed restricted to only single and dual-chamber LBBAP implants. Results A total of 1374 patients were enrolled in the primary INSIGHT-LBBA registry. Overall LBBAP success and LBB capture success rate was 94.5% and 78.1%, respectively. LBBAP success improved with experience (OR 1.09 [1.03 – 1.14] per every 10 successive LBBAP implants, p=0.001), with similar results in the sensitivity analysis. Fluoroscopy times and complication rates remained low (10.0 ± 9.2 min, and 2.7%, respectively). Conclusion In this secondary analysis of INSIGHT-LBBA utilizing INGEVITY+ SDLs, LBBAP and LBB capture success rates were high and improved with consecutive implants, indicative of a learning curve for implantation. Fluoroscopy times and complications rates remained low without significant change during consecutive implants. These data add to the growing literature supporting safe and effective use of SDLs for LBBAP.

Background Patients with anticoagulation‐associated intracerebral hemorrhage are often transferred from the presenting hospital to one with additional resources. Understanding differences in timeliness and care, including anticoagulant reversal, between transfer and direct admissions may identify quality improvement opportunities. Methods This cross‐sectional study included all hospitals in the American Heart Association GWTG–Stroke (Get With The Guidelines–Stroke) registry where anticoagulant reversal was administered (2015–2021). Patients with anticoagulation‐associated intracerebral hemorrhage presenting within 24 hours of onset and with information on prior AC treatment were included. Outcomes included functional score at discharge, in‐hospital death/discharge to hospice, discharge ambulatory status, discharge destination, and length of stay. Results Of 30 590 patients with AC‐ICH, 14 882 (48.6%) were transfers. Symptom onset to AC reversal was longer for transfer patients who received anticoagulant reversal at the admitting hospital versus direct‐admission patients (512 [interquartile range 328–840] versus 273 [interquartile range, 153–579] minutes; absolute standardized mean difference, 75.9%). Transfer patients had milder stroke severity on admission versus direct‐admission patients on the basis of National Institute of Health Stroke Scale (7 [interquartile range, 2–19] versus 11 [interquartile range, 3–22]; absolute standardized mean difference, 21.2%) and intracerebral hemorrhage scores (1.81±1.36 versus 2.02±1.47; absolute standardized mean difference, 13.7%). In an adjusted logistic regression model, transfer patients had lower odds of in‐hospital death/discharge to hospice (adjusted odds ratio, 0.78 [95% CI, 0.72–0.85]), but no difference in discharge functional score, ambulatory status, or discharge home versus direct‐admission patients. Conclusions Transfer patients with anticoagulation‐associated intracerebral hemorrhage had longer times to reversal at the admitting hospital, less severe intracerebral hemorrhage, and lower odds of in‐hospital death versus direct‐admission patients after adjustment.

Background Lowering low-density lipoprotein cholesterol (LDL-C) to guideline-based goals is essential in the management of patients with atherosclerotic cardiovascular disease (ASCVD). Yet, real world evidence indicates that LDL-C is infrequently tested after an ASCVD event, and many patients remain with uncontrolled LDL-C. Methods Test 2 Treat is an implementation study that aims to assess the impact of multifaceted health system and patient-level interventions to improve LDL-C testing and management in patients hospitalized with myocardial infarction (MI) and/or percutaneous coronary revascularization (PCI). The study is divided into two components: one component is a hospital-level implementation intervention based on system specific barriers to improve LDL-C testing and management; and the other component is a patient-level 1:1 randomized controlled trial that tests the impact of a care champion to help coordinate care for patients discharged after a MI and/or PCI compared to usual care. Results Five health systems are included in the hospital-level component and six health systems in the patient level component. A total of 399 patients enrolled in the patient level component from 10/8/2024 to 11/20/2025. Baseline characteristics of those enrolled include a mean age of 63.5 ±11.7 years, 37.8% female, and 16.8% Black/African American. Additionally, 33.4% presented with STEMI, 49.2% with type 1 NSTEMI, and 17.1% PCI without MI. The mean LDL-C across both arms at baseline was 117.6 ± 32.2 mg/dL, and 78.6% were on high intensity statin at discharge. Conclusions Overall, Test 2 Treat aims to discover effective, adaptable, and scalable strategies to reduce LDL-C in high-risk patients.

Musculoskeletal pain conditions are prevalent and costly, with practice guidelines consistently recommending non-pharmacologic interventions as first-line treatments. Physical therapists are common providers of non-pharmacologic pain care, and early access to their services is believed to reduce the risk of care intensification, including opioid use, injections, surgery, and emergency department visits. New programs that remove visit copays to encourage early use of physical therapy are being implemented, but intensification rates and predictors of intensification among patients that use these programs are poorly understood. This study aims to (1) describe care intensification rates and (2) identify patient-level factors associated with the intensification of care among beneficiaries using a program that removes co-pays to promote early access physical therapy for musculoskeletal conditions. A secondary analysis was conducted using retrospective health care claims and registry data from patients initiating care in a no co-pay physical therapy program. The study included patients (n = 1,171) treated for musculoskeletal conditions between April 2020 and June 2021. Care intensification was defined as the receipt of advanced imaging, injections, surgery, or opioid prescriptions within 30 days and 12 months following the initiation of physical therapy. In the 12 months following program initiation, 13.1

Importance:Although P2Y purinergic receptor 12 (P2Y12) inhibitors are commonly used in patients with atherosclerotic cardiovascular disease, there are limited data on intracerebral hemorrhage (ICH) associated with use of P2Y12 inhibitors. Objective:To compare stroke severity, in-hospital mortality, and functional outcomes in ICH among patients receiving P2Y12 inhibitor monotherapy, dual antiplatelet therapy (DAPT) with P2Y12 inhibitor plus aspirin, aspirin monotherapy, or no antiplatelet therapy prior to ICH. Design, Setting, and Participants:This cohort study obtained data from the nationwide Get With The Guidelines-Stroke registry, which contains data from participating hospitals. Participants were patients hospitalized with spontaneous ICH between January 2013 to December 2021. The analysis was completed in January 2025. Exposures:Antiplatelet therapy before ICH, defined as any use within 7 days prior to hospital arrival. Main Outcomes and Measures:The primary outcomes were severe stroke at presentation and in-hospital mortality. Severity was assessed using the National Institutes of Health Stroke Scale (NIHSS; range: 0-42, with higher scores indicating greater severity), with a score of 21 or higher indicating severe stroke. Secondary outcomes included in-hospital mortality or discharge to hospice, discharge to home, independent ambulation, and modified Rankin Scale (mRS) score at discharge. An mRS score of 0 to 2 at discharge indicated functional independence. Results:Of the 252 691 patients included (median [IQR] age, 67 [56-78] years; 134 684 males [53.3%]), 6355 (2.5%) were receiving P2Y12 inhibitor monotherapy, 10 607 (4.2%) were receiving DAPT, 63 299 (25.0%) were receiving aspirin monotherapy, and 172 430 (68.2%) were receiving no antiplatelet agents prior to ICH. Patients taking P2Y12 inhibitors were older and had higher prevalence of cardiovascular risk factors. Overall, 1701 patients (26.8%) receiving P2Y12 monotherapy and 2688 patients (25.3%) receiving DAPT experienced severe ICH (NIHSS score ≥21) compared with 12 952 patients (20.5%) who used aspirin monotherapy and 39 970 (23.2%) patients who received no antiplatelet (P < .001). In-hospital mortality rates were highest in patients using DAPT (24.0%), followed by patients receiving P2Y12 inhibitor monotherapy (23.8%), no antiplatelet (16.8%), and aspirin monotherapy (16.5%) (P < .001). After risk adjustment, patients with prior use of P2Y12 inhibitors were more likely to present with severe stroke (P2Y12 inhibitor monotherapy: adjusted odds ratio [AOR], 1.43 [95% CI, 1.34-1.52]; P < .001; DAPT: AOR, 1.40 [95% CI, 1.33-1.47]; P < .001) and more likely to die in the hospital (P2Y12 inhibitor monotherapy: AOR, 1.55 [95% CI, 1.46-1.66]; P < .001; DAPT: AOR, 1.61 [95% CI, 1.53-1.71]; P < .001) compared with those using aspirin monotherapy. Furthermore, these patients were less likely to be discharged to home, be able to ambulate independently, or have functional independence at discharge. In contrast, there were no statistically significant differences in in-hospital outcomes between aspirin monotherapy and no antiplatelet therapy groups. Conclusions and Relevance:In this registry-based cohort study of patients with ICH not associated with anticoagulation, P2Y12 inhibitors, either as monotherapy or in combination with aspirin, were associated with more severe stroke, in-hospital death, worse clinical outcomes, and reduced functional recovery compared with aspirin monotherapy or no antiplatelet therapy.

Introduction/Background: Hospital at Home (HaH) is an emerging, patient-centered clinical model by which patients receive inpatient-level care at home. HaH may be particularly well-suited to the care of patients with worsening heart failure (WHF). Research Questions: Our study sought to examine, if implemented widely, what proportion of US patients hospitalized with WHF would be eligible for HaH care. We also sought to determine the clinical and demographic differences between HaH eligible and ineligible populations. Methods/Approach: Among US patients hospitalized for WHF in the Get With The Guidelines – Heart Failure (GWTG-HF) registry from 2021-2024, we applied generally accepted and/or required (by Medicare) social and clinical criteria for HaH to estimate the proportion of patients potentially eligible for HaH. We then further compared the demographics, vital signs and laboratory findings, comorbidities, mortality, and length of stay for the HaH eligible and ineligible groups. Results/Data: Among 81,610 patients hospitalized across 204 sites, 49,544 (60.7%) were projected as eligible for HaH (Table 1) . Eligibility rates were >50% across demographic and geographic subgroups but tended to be higher among patients age >75 years, women, and Hispanic patients, as well as among patients hospitalized in urban areas and the Northeast US (Figure) . Eligible patients were less likely to have a history of chronic kidney disease and had a lower median GWTG-HF risk score (Table 2) . Patients eligible for HaH had lower in-hospital mortality and shorter length of stay (Table 2) . Conclusions: In this nationwide cohort of US patients hospitalized for WHF, approximately 6 out of 10 patients were projected as potentially eligible for HaH, with modest variability across demographic and geographic subgroups. Patients eligible for HaH demonstrated a lower risk clinical profile. HaH could conceivably be a viable treatment strategy for the majority of US patients with WHF, and national efforts to continue or expand HaH have the potential to substantially impact WHF care delivery.

Background: Transthyretin amyloid cardiomyopathy (ATTR-CM) is associated with high risk for heart failure (HF) hospitalization. However, little is known regarding post-discharge outcomes and healthcare costs for patients with underlying ATTR-CM, as compared with the general HF population. Methods: We analyzed Medicare beneficiaries hospitalized for HF in the Get With The Guidelines-Heart Failure (GWTG-HF) registry and discharged alive from January 1, 2021, to June 30, 2023. Patients were compared according to the presence or absence of an ATTR-CM diagnosis, as documented in the GWTG-HF case report form. All-cause mortality, HF readmission, and all-cause readmission over 1-year post-discharge were assessed in unadjusted and adjusted risk models. Inpatient, outpatient (excluding medications), and total per-patient healthcare costs over the 1-year post-discharge were calculated from payments made by Medicare. Results: Among 102,160 patients across 563 US hospitals, 190 (0.2%) carried a diagnosis of ATTR-CM. Compared to those without ATTR-CM, patients with an ATTR-CM diagnosis were older (82 [76–87] vs 80 [73–87] years), more likely to be male (68.9% vs 47.0%), and had lower ejection fraction (45 [30–57] vs 53 [35–60]%). Patients with ATTR-CM were significantly more likely to be discharged on a mineralocorticoid receptor antagonist (29.5% vs 20.4%) and SGLT2 inhibitor (21.6% vs 14.1%), and significantly less likely to be discharged on a beta-blocker (52.1% vs 77.6%). After adjustment, ATTR-CM was associated with higher risk of 1-year HF readmission (36.8% vs. 28.2%; HR 1.28, 95% CI 1.01–1.61, p=0.04), but not all-cause mortality (40.0% vs. 34.2%; HR 1.08, 95% CI 0.88–1.31, p=0.47) or all-cause readmission (64.2% vs. 63.4%; HR 0.98, 95% CI 0.83–1.17, p=0.85) (Table 1) . Mean 1-year total per-patient Medicare costs were higher among patients with ATTR-CM than those without ($60,373 vs $50,247; p=0.04), primarily driven by significant differences in outpatient costs ($20,866 vs $16,358]; p=0.03) (Table 2) . Conclusion: Among older adults hospitalized for HF in the US, patients with underlying ATTR-CM experience similarly high rates of post-discharge mortality, but face greater risks of HF readmission and accrue higher post-discharge healthcare costs. These findings highlight a disproportionate clinical and economic burden of ATTR-CM compared with the general HF population, further supporting the need for earlier identification and tailored care strategies.

BACKGROUND:Racial disparities have been reported in stroke care, but understanding if there is regional variability is critical to focusing policies and resources. Here, we sought to study racial and ethnic inequity in the administration of thrombolysis and thrombectomy at the national and state levels. METHODS:We conducted a retrospective cohort study using Get With The Guidelines-Stroke Program registry data from 2003 to 2022 to evaluate racial disparities in the administration of acute stroke treatments in US patients. We used mixed-effects modeling to analyze national and state-level disparities, adjusting for relevant demographic, clinical, and hospital-level characteristics. RESULTS:A total of 660 369 patients were eligible for thrombolysis and 105 184 patients for thrombectomy. The mean age was 70.21±14.48 years, and 50.18% were female. The race/ethnic distribution was 69.06% of non-Hispanic White, 16.88% of non-Hispanic Black, 7.02% of Hispanic, 2.84% of Asian, and 4.20% of American Indian/Alaska Native/Hawaiian/Pacific Islander patients. Eligible non-Hispanic Black patients had statistically higher thrombolytic rates compared with non-Hispanic White patients (adjusted odds ratio [aOR], 1.04 [95% CI, 1.03-1.06]), indicating no racial disparities in thrombolytic treatment at the national level. Similarly, equal or higher rates of thrombolytic administration were noted in other race/ethnic groups at the national level (Asian: aOR, 1.12 [95% CI, 1.09-1.16]; Hispanic: aOR, 1.14 [95% CI, 1.12-1.17]; and other: aOR, 1.10 [95% CI, 1.07-1.13]; P<0.0001). However, when non-Hispanic Black patients were compared with non-Hispanic White patients at the individual state level, there were disparities in many of the stroke-belt states. Racial disparities remained significant at the national level between non-Hispanic Black and non-Hispanic White patients and eligible thrombectomy patients after adjusting for patient- and hospital-level covariates (aOR, 0.85 [95% CI, 0.82-0.89]; P<0.0001). CONCLUSIONS:These data suggest that racial/ethnic disparities in stroke care vary depending on the intervention and geographic location. Equitable utilization of thrombolysis nationally may underscore the benefits of quality improvement initiatives though state-level inequities persist. Endovascular thrombectomy utilization demonstrated race-based disparities in use, and further efforts are needed to ensure equitable care of patients with stroke in the United States.

Importance:Tenecteplase is an alternative to alteplase for emergency treatment of acute ischemic stroke. However, limited data are available comparing their clinical effectiveness in routine clinical practice. Objective:To compare short-term effectiveness and safety outcomes for patients with ischemic stroke treated with intravenous tenecteplase vs alteplase. Design, Setting, and Participants:This comparative effectiveness study used data prospectively collected from July 1, 2020, through June 30, 2022, from the Get With The Guidelines-Stroke registry. Exposure:Consecutive patients with ischemic stroke treated with either tenecteplase or alteplase within 4.5 hours from last known well time were included. Main Outcomes and Measures:The primary end point was functional independence on discharge (modified Rankin Scale [mRS] score, 0-2). Secondary effectiveness end points included disability free at discharge (mRS score, 0-1), discharge home, and independent ambulation at discharge. Safety end points included symptomatic intracranial hemorrhage (sICH) within 36 hours and combined in-hospital mortality or hospice discharge. Generalized linear mixed models were fit to evaluate associations between exposure to tenecteplase (vs alteplase) and end points after adjustment for demographic, clinical, and hospital-level variables. Adjusted odds ratios (AORs) with 95% CIs were computed. Results:Among 79 550 patients treated with intravenous thrombolysis, the mean (SD) age was 68.6 (14.8) years, 38 596 (48.5%) were female, and the median National Institutes of Health Stroke Scale (NIHSS) score was 7 (IQR, 4-13). Of these patients, 9465 (11.9%) received tenecteplase (mean [SD] age, 69.6 [14.7] years; median NIHSS score, 7 [IQR, 4-14]; 4504 [47.6%] female) and 70 085 (88.1%) received alteplase (mean [SD] age, 68.5 [14.8] years; median NIHSS score, 7 [IQR, 4-13]; 34 092 [48.6%] female). After adjustment for covariates, no significant differences were found between tenecteplase and alteplase in effectiveness or safety outcomes for the overall cohort, including functional independence at discharge (AOR, 1.00; 95% CI, 0.93-1.07), sICH (AOR, 0.96; 95% CI, 0.83-1.11), and in-hospital mortality or hospice discharge (AOR, 0.98; 95% CI, 0.89-1.07), but significant improvement was found in discharge home (AOR, 1.26; 95% CI, 1.03-1.53), in-hospital mortality (AOR, 0.63; 95% CI, 0.47-0.85), and composite in-hospital mortality or hospice discharge (AOR, 0.78; 95% CI, 0.62-0.97) among those who were eligible for but did not undergo endovascular thrombectomy. Conclusions and Relevance:This large, nationwide comparative effectiveness study using data from routine clinical practice demonstrated similar effectiveness and safety outcomes with tenecteplase compared with alteplase in patients with acute ischemic stroke. This study supports tenecteplase as a reasonable alternative to alteplase.