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Background We report the interim results of a process improvement initiative at a comprehensive stroke center in which all tPA (tissue‐type plasminogen activator)–eligible patients were given tenecteplase for acute ischemic stroke. Methods We retrospectively analyzed a prospectively maintained single‐center registry of consecutive patients with acute ischemic stroke treated at our comprehensive stroke center emergency department or transferred for further care. Patients treated with alteplase (tPA) before the process improvement initiative (October 2019–April 2020) were compared with those treated with tenecteplase (May 2020–July 2021). The primary efficacy outcome was the Target: Stroke Phase II recommendation of door‐to‐needle (DTN) time ≤45 minutes. Backward stepwise logistic regression was used to estimate an independent effect of tenecteplase against DTN time ≤45 minutes. Two contemporaneous, negative controls (time to first emergency department antibiotic for patients who presented with infectious symptoms and door‐to‐groin puncture for thrombectomy) were evaluated to confirm DTN time was unrelated to emergency department and other stroke treatment throughput. Results Of the 113 included patients, 53 (47%) received tenecteplase. DTN time was significantly faster in patients treated with tenecteplase (median, 41 [interquartile range, 34–62] minutes versus 58 [interquartile range, 45–70] minutes; P <0.01), with no significant difference in symptomatic intracranial hemorrhage (2% versus 7%; P =0.37). Despite the higher proportion of tPA patients being transferred for care (with slower DTN time), tenecteplase remained independently predictive of DTN time ≤45 minutes (adjusted odds ratio, 3.96; 95% CI, 1.58–9.91). There was no difference in time to first emergency department antibiotic ( P >0.05) or door‐to‐puncture ( P >0.05) when similar periods were compared. Conclusions Tenecteplase was associated with faster DTN time when compared with tPA in those with acute ischemic stroke. This can likely be attributed to the ease of single bolus administration of tenecteplase.

PurposeInsufficient data exist regarding the benefit of long-term antiplatelet vs. anticoagulant therapy in the prevention of recurrent ischemic stroke in patients with ischemic stroke and heart failure with reduced ejection fraction (HFrEF). Therefore, this study aimed to compare longitudinal outcomes associated with antiplatelet vs. anticoagulant use in a cohort of patients with stroke and with an ejection fraction of ≤40%.MethodsWe retrospectively analyzed single-center registry data (2015–2021) of patients with ischemic stroke, HFrEF, and sinus rhythm. Time to the primary outcome of recurrent ischemic stroke, major bleeding, or death was assessed using the adjusted Cox proportional hazards model and was compared between patients treated using anticoagulation (±antiplatelet) vs. antiplatelet therapy alone after propensity score matching using an intention-to-treat (ITT) approach, with adjustment for residual measurable confounders. Sensitivity analyses included the multivariable Cox proportional hazards model using ITT and as-treated approaches without propensity score matching.ResultsOf 2,974 screened patients, 217 were included in the secondary analyses, with 130 patients matched according to the propensity score for receiving anticoagulation treatment for the primary analysis, spanning 143 patient-years of follow-up. After propensity score matching, there was no significant association between anticoagulation and the primary outcome [hazard ratio (HR) 1.10, 95% confidence interval (CI): 0.56–2.17]. Non-White race (HR 2.26, 95% CI: 1.16–4.41) and the presence of intracranial occlusion (HR 2.86, 95% CI: 1.40–5.83) were independently associated with the primary outcome, while hypertension was inversely associated (HR 0.42, 95% CI: 0.21–0.84). There remained no significant association between anticoagulation and the primary outcome in sensitivity analyses.ConclusionIn HFrEF patients with an acute stroke, there was no difference in outcomes of antithrombotic strategies. While this study was limited by non-randomized treatment allocation, the results support future trials of stroke patients with HFrEF which may randomize patients to anticoagulation or antiplatelet.