AHA Issues Scientific Statement on Optimizing Treatment for In-Hospital Stroke

The American Heart Association (AHA) has issued recommendations to help clinicians improve the evaluation and management of patients who experience an in-hospital stroke, according to a scientific statement published in Stroke.

An in-hospital stroke is defined as “a stroke that occurs during a hospitalization for another diagnosis.” In order to ensure optimized care, the AHA recommends the development of hospital systems of care and targeted quality improvement for this patient population.

The AHA’s 5 core elements for the optimization of in-hospital stroke care include:

1. Deliver stroke training to all hospital staff, including how to activate in-hospital stroke alerts.
2. Create rapid response teams with dedicated stroke training and immediate access to neurologic expertise.
3. Standardize the evaluation of patients with potential in-hospital stroke by using physical evaluation and imaging.
4. Address potential barriers to treatment, which includes interfacility transfer to advanced stroke treatment.
5. Establish an in-hospital stroke quality oversight program that delivers data-driven performance feedback and drives targeted quality improvement efforts.

A key takeaway is that additional research is warranted to better understand how to decrease the incidence, morbidity, and mortality of in-hospital stroke.

The introduction of new therapeutic options for patients who experience acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) renders an accurate, timely diagnosis an important issue with respect to in-hospital stroke. New treatment strategies utilize hyperacute advanced imaging to select patients who experience AIS for early reperfusion treatments and have expanded the available options for the treatment of ICH, which includes the use of minimally invasive surgical techniques. All of the major treatments, such as intravenous alteplase and mechanical thrombectomy, were developed in clinical trials that enrolled mainly those patients who experienced community-onset stroke and were initially evaluated in a hospital emergency department (ED). Much difficulty has been encountered when attempting to translate these treatments to patients who experience an in-hospital stroke, because of the additional clinical complexities and the lack of standardized protocols.

With evidence-based guidelines and practice recommendations focusing on patients who present to an ED, the current scientific statement seeks to translate advances in the ED management of patients with acute stroke to patients who experience an in-hospital stroke.

All of the writing group members were nominated by the committee chairperson and vice chairperson based on their areas of expertise and prior work in relevant topic areas. The members were all approved by the AHA Stroke Council’s Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The participating disciplines were neurology, internal medicine, neurocritical care, neurosurgery, neurointerventional radiology, and nursing. A literature search was conducted of English-language articles pertaining to in-hospital stroke that were published between 1996 and 2020. The evidence was reviewed and organized with guidance from the AHA, and the final manuscript was approved by the entire writing group.

A limited amount of data verify that the incidence of stroke occurring among all hospitalized patients is low and likely varies based on the service. Although no large, validated, multivariable studies have accurately classified hospitalized patients by risk for in-hospital stroke, patients with a cardiovascular diagnosis are at a particularly high risk. In fact, nearly half of all in-hospital stroke events happen within 24 hours of a cardiac or neurovascular procedure, with vascular trauma during one of these procedures resulting in dissection or disruption of atherothrombotic material.

Between 2% and 4% of patients who experience a stroke have their event during a hospitalization for another condition. Risk factors for spontaneous in-hospital stroke include hemodynamic, rheologic, and inflammatory/prothrombotic conditions that are associated with the acute illness. Discontinuation of antithrombotic medication can elevate the risk for periprocedural stroke. Patients who are admitted to the hospital for a transient ischemic attack are at an increased risk for experiencing an in-hospital stroke. Approximately 50% of all in-hospital stroke alerts are ultimately determined to be a stroke mimic.

The assessment of patients who experience an in-hospital stroke may be delayed or inaccurate because of complicating factors. The time from symptom onset to stroke alert is often delayed in patients who experience an in-hospital stroke. “Reviewing metrics such as the number of in-hospital stroke alerts, true stroke rates with subtypes, response times, imaging acquisition times, treatment rates, treatment times, and outcomes will support quality improvement and identify potential barriers and opportunities,” the researchers stated.

They concluded by noting that the following key components should be in place in order to optimize the assessment and management of patients who experience an
in-hospital stroke:

1. Ongoing stroke education
2. In-hospital stroke response teams
3. Processes and written protocols
4. Identification of challenges, barriers, and limitations
5. Quality improvement

Disclosure: One of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of the author’s disclosures. 

Reference  

Nouh A, Amin-Hanjani S, Furie KL, et al; American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Council on Lifestyle and Cardiometabolic Health. Identifying best practices to improve evaluation and management of in-hospital stroke: a scientific statement from the American Heart Association. Stroke. Published online February 9, 2022. doi:10.1161/STR.0000000000000402