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image of Utilization Trends and Outcomes of Alteplase in Acute Cerebral Ischemia among Patients with Hypertension or Diabetes: A Tertiary Care Experience from Southern Punjab

Abstract

Objective

Stroke is the second leading cause of death and the third leading cause of disability worldwide, with hypertension and diabetes mellitus being its most prominent risk factors. This study aims to assess the utilization trends and clinical outcomes of Alteplase in patients presenting with acute cerebral ischemia and known history of hypertension and/or diabetes, within our local population in Southern Punjab, Pakistan-a region with limited stroke care infrastructure.

Methods

This observational study was conducted at the emergency department of a tertiary care hospital. A total of 106 patients presenting with acute cerebral ischemia confirmed CT scan and/or MRI were enrolled. All patients had a documented history of hypertension (n = 91), diabetes mellitus (n = 27), or both (n = 64). Patients who presented within 4.5 hours of symptom onset and met standard inclusion criteria were administered intravenous Alteplase as per AHA/ASA guidelines. Patients were divided into two groups: Group 1 (received Alteplase, n = 56) and Group 2 (did not receive Alteplase, n = 82). Outcomes were measured using the modified Rankin Scale (mRS) at 3 months post-intervention, with favorable recovery defined as mRS 0-2.

Results

Of the 44 patients who received Alteplase, 66% (n = 37) achieved favorable outcomes (mRS 0-2). In contrast, only 39% (n = 32) of the 62 patients in the non-Alteplase group had favorable recovery. No significant increase in hemorrhagic complications was observed in the Alteplase group.

Conclusion

In patients with acute cerebral ischemia and pre-existing hypertension or diabetes, the timely administration of Alteplase significantly improves functional outcomes. Despite its proven efficacy, access to thrombolytic therapy remains inadequate in public sector hospitals in Southern Punjab. Efforts must be made to expand stroke services and standardize acute stroke care across the region.

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2025-06-19
2025-09-25

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References

  1. Ahmad S. Acute ischemic stroke treatment barriers in Pakistan. Pakistan Journal of Neurological Sciences 2020 15 4 4 6
    [Google Scholar]
  2. Donkor E.S. Stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life. Stroke Res. Treat. 2018 2018 1 3238165 [PMID: 30598741
    [Google Scholar]
  3. Mansoor S.N. Rathore F.A. Ikram M. Stroke rehabilitation services in pakistan: current status and future directions. KHYBER MEDICAL UNIVERSITY JOURNAL 2020 12 4 333 335
    [Google Scholar]
  4. Sajjad Z. Neuro-imaging facilities in Pakistan. J. Pak. Med. Assoc. 2003 53 12 621 623
    [Google Scholar]
  5. Li A. Ji Y. Zhu S. Hu Z. Xu X. Wang Y. Jian X. Risk probability and influencing factors of stroke in followed-up hypertension patients. BMC Cardiovasc. Disord. 2022 22 1 328 10.1186/s12872‑022‑02780‑w 35871681
    [Google Scholar]
  6. Huo Y. Li J. Qin X. Huang Y. Wang X. Gottesman R.F. Tang G. Wang B. Chen D. He M. Fu J. Cai Y. Shi X. Zhang Y. Cui Y. Sun N. Li X. Cheng X. Wang J. Yang X. Yang T. Xiao C. Zhao G. Dong Q. Zhu D. Wang X. Ge J. Zhao L. Hu D. Liu L. Hou F.F. Efficacy of folic acid therapy in primary prevention of stroke among adults with hypertension in China: the CSPPT randomized clinical trial. JAMA 2015 313 13 1325 1335 10.1001/jama.2015.2274 25771069
    [Google Scholar]
  7. Hu L. Huang X. Zhou W. You C. Liang Q. Zhou D. Li J. Li P. Wu Y. Wu Q. Wang Z. Gao R. Bao H. Cheng X. Associations between resting heart rate, hypertension, and stroke: A population‐based cross‐sectional study. J. Clin. Hypertens. (Greenwich) 2019 21 5 589 597 10.1111/jch.13529 30950555
    [Google Scholar]
  8. Wajngarten M. Silva G.S. Hypertension and stroke: update on treatment. Eur. Cardiol. 2019 14 2 111 115 10.15420/ecr.2019.11.1 31360232
    [Google Scholar]
  9. Feigin V.L. Norrving B. Mensah G.A. Global burden of stroke. Circ. Res. 2017 120 3 439 448 10.1161/CIRCRESAHA.116.308413 28154096
    [Google Scholar]
  10. O’Donnell M.J. Xavier D. Liu L. Zhang H. Chin S.L. Rao-Melacini P. Rangarajan S. Islam S. Pais P. McQueen M.J. Mondo C. Damasceno A. Lopez-Jaramillo P. Hankey G.J. Dans, A.L.; Yusoff, K.; Truelsen, T.; Diener, H.C.; Sacco, R.L.; Ryglewicz, D.; Czlonkowska, A.; Weimar, C.; Wang, X.; Yusuf, S. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010 376 9735 112 123 10.1016/S0140‑6736(10)60834‑3 20561675
    [Google Scholar]
  11. Mosenzon O. Cheng A.Y.Y. Rabinstein A.A. Sacco S. Diabetes and stroke: what are the connections? J. Stroke 2023 25 1 26 38 10.5853/jos.2022.02306 36592968
    [Google Scholar]
  12. Meschia J.F. Bushnell C. Boden-Albala B. Braun L.T. Bravata D.M. Chaturvedi S. Creager M.A. Eckel R.H. Elkind M.S.V. Fornage M. Goldstein L.B. Greenberg S.M. Horvath S.E. Iadecola C. Jauch E.C. Moore W.S. Wilson J.A. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014 45 12 3754 3832 10.1161/STR.0000000000000046 25355838
    [Google Scholar]
  13. Anwar A. Saleem S. Aamir A. Diwan M. Organization of stroke care in Pakistan. Int. J. Stroke 2020 15 5 565 566 10.1177/1747493019879663 31564238
    [Google Scholar]
  14. Malik A. Khatri I. Wasay M. Stroke manifesto-What must be done for stroke care in Pakistan. Pakistan Journal of Neurological Sciences 2015 10 3 1 3
    [Google Scholar]
  15. Khealani B.A. Hameed B. Mapari U.U. Stroke in Pakistan. J. Pak. Med. Assoc. 2008 58 7 400 403 [PMID: 18988415
    [Google Scholar]
  16. Farooq M.U. Majid A. Reeves M.J. Birbeck G.L. The epidemiology of stroke in Pakistan: past, present, and future. Int. J. Stroke 2009 4 5 381 389 10.1111/j.1747‑4949.2009.00327.x 19765127
    [Google Scholar]
  17. BA K.; ZF, J.; NA, S. Cost of acute stroke care at a tertiary care hospital in Karachi, Pakistan. J. Pak. Med. Assoc. 2003 53 11 552 555
    [Google Scholar]
  18. Wasay M. Future of neurology in Pakistan. Pakistan Journal of Neurological Sciences 2010 5 1 iv v
    [Google Scholar]
  19. Wasay M. Present and future of neurology in Pakistan. Pakistan Journal of Neurological Sciences 2016 11 1 1 2
    [Google Scholar]
  20. Kakuda W. Optimal definition for PWI/DWI mismatch in acute ischemic stroke. Stroke 2007 38 2 454 454
    [Google Scholar]
  21. Thiebaut A.M. Gauberti M. Ali C. Martinez De Lizarrondo S. Vivien D. Yepes M. Roussel B.D. The role of plasminogen activators in stroke treatment: fibrinolysis and beyond. Lancet Neurol. 2018 17 12 1121 1132 10.1016/S1474‑4422(18)30323‑5 30507392
    [Google Scholar]
  22. Wahlgren N. Ahmed N. Dávalos A. Ford G.A. Grond M. Hacke W. Hennerici M.G. Kaste M. Kuelkens S. Larrue V. Lees K.R. Roine R.O. Soinne L. Toni D. Vanhooren G. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 2007 369 9558 275 282 10.1016/S0140‑6736(07)60149‑4 17258667
    [Google Scholar]
  23. Hacke W. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N. Engl. J. Med. 2007 358 1327 [PMID: 18815396
    [Google Scholar]
  24. Sekovanić J. Repeated intravenous thrombolytic therapy with rt-PA alteplase in treatment of early recurrent ischemic stroke. Medical Sciences 2023 556 62-63 98 103 10.21857/ygjwrcp78y
    [Google Scholar]
  25. Marè A. Lorenzut S. Janes F. Gentile C. Marinig R. Tereshko Y. Gigli G.L. Valente M. Merlino G. Comparison of pharmacokinetic properties of alteplase and tenecteplase. The future of thrombolysis in acute ischemic stroke. Expert Opin. Drug Metab. Toxicol. 2024 20 1-2 25 36 10.1080/17425255.2024.2311168 38275111
    [Google Scholar]
  26. Diedler J. Ahmed N. Glahn J. Grond M. Lorenzano S. Brozman M. Sykora M. Ringleb P. Is the maximum dose of 90 mg alteplase sufficient for patients with ischemic stroke weighing 100 kg? Stroke 2011 42 6 1615 1620 10.1161/STROKEAHA.110.603514 21493905
    [Google Scholar]
  27. Reed M. Kerndt C.C. Nicolas D. Alteplase In: Statspearl;National library of medicine 2023 2 7
    [Google Scholar]
  28. Berge E. Whiteley W. Audebert H. De Marchis G.M. Fonseca A.C. Padiglioni C. Pérez de la Ossa N. Strbian D. Tsivgoulis G. Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur. Stroke J. 2021 6 1 I LXII 10.1177/2396987321989865 33817340
    [Google Scholar]
  29. Fugate J.E. Rabinstein A.A. Absolute and relative contraindications to IV rt-PA for acute ischemic stroke. Neurohospitalist 2015 5 3 110 121 10.1177/1941874415578532 26288669
    [Google Scholar]
  30. Ogata T. Christensen S. Nagakane Y. Ma H. Campbell B.C.V. Churilov L. Lansberg M.G. Straka M. De Silva D.A. Mlynash M. Bammer R. Olivot J.M. Desmond P.M. Albers G.W. Davis S.M. Donnan G.A. The effects of alteplase 3 to 6 hours after stroke in the EPITHET-DEFUSE combined dataset: post hoc case-control study. Stroke 2013 44 1 87 93 10.1161/STROKEAHA.112.668301 23250996
    [Google Scholar]
  31. Hacke W. Donnan G. Fieschi C. Kaste M. von Kummer R. Broderick J.P. Brott T. Frankel M. Grotta J.C. Haley E.C. Kwiatkowski T. Levine S.R. Lewandowski C. Lu M. Lyden P. Marler J.R. Patel S. Tilley B.C. Albers G. Bluhmki E. Wilhelm M. Hamilton S. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004 363 9411 768 774 10.1016/S0140‑6736(04)15692‑4 15016487
    [Google Scholar]
  32. Iqbal A. Haider S.A. Kazmi S. Limitations to intravenous thrombolytic therapy in acute ischemic stroke in our settings. Pak. J. Med. Health Sci. 2016 10 3 1047 1049
    [Google Scholar]
  33. Muruet W. Rudd A. Wolfe C.D.A. Douiri A. Long-term survival after intravenous thrombolysis for ischemic stroke: a propensity score-matched cohort with up to 10-year follow-up. Stroke 2018 49 3 607 613 10.1161/STROKEAHA.117.019889 29440582
    [Google Scholar]
  34. Nomani A.Z. Nabi S. Badshah M. Ahmed S. Review of acute ischaemic stroke in Pakistan: progress in management and future perspectives. Stroke Vasc. Neurol. 2017 2 1 30 39 10.1136/svn‑2016‑000041 28959488
    [Google Scholar]
  35. Ghandehari K. Barriers of thrombolysis therapy in developing countries. Stroke Res. Treat. 2011 2011 1 1 4 10.4061/2011/686797 21603174
    [Google Scholar]
  36. Jafar T.H. Blood pressure, diabetes, and increased dietary salt associated with stroke – results from a community-based study in Pakistan. J. Hum. Hypertens. 2006 20 1 83 85 10.1038/sj.jhh.1001929 16151442
    [Google Scholar]
  37. Hedna V.S. Bodhit A.N. Ansari S. Falchook A.D. Stead L. Heilman K.M. Waters M.F. Hemispheric differences in ischemic stroke: is left-hemisphere stroke more common? J. Clin. Neurol. 2013 9 2 97 102 10.3988/jcn.2013.9.2.97 23626647
    [Google Scholar]
  38. Naess H. Waje-Andreassen U. Thomassen L. Myhr K.M. High incidence of infarction in the left cerebral hemisphere among young adults. J. Stroke Cerebrovasc. Dis. 2006 15 6 241 244 10.1016/j.jstrokecerebrovasdis.2006.06.003 17904082
    [Google Scholar]
  39. Rexrode K.M. Madsen T.E. Yu A.Y.X. Carcel C. Lichtman J.H. Miller E.C. The impact of sex and gender on stroke. Circ. Res. 2022 130 4 512 528 10.1161/CIRCRESAHA.121.319915 35175851
    [Google Scholar]
  40. Abdu H. Seyoum G. Sex differences in stroke risk factors, clinical profiles, and in-hospital outcomes among stroke patients admitted to the medical ward of Dessie comprehensive specialized hospital, Northeast Ethiopia. Degener. Neurol. Neuromuscul. Dis. 2022 12 133 144 10.2147/DNND.S383564 36304698
    [Google Scholar]
  41. Hiraga A. Gender differences and stroke outcomes. Neuroepidemiology 2017 48 1-2 61 62 10.1159/000475451 28419999
    [Google Scholar]
  42. Reeves M.J. Bushnell C.D. Howard G. Gargano J.W. Duncan P.W. Lynch G. Khatiwoda A. Lisabeth L. Sex differences in stroke: epidemiology, clinical presentation, medical care, and outcomes. Lancet Neurol. 2008 7 10 915 926 10.1016/S1474‑4422(08)70193‑5 18722812
    [Google Scholar]
  43. Roger V.L. Go A.S. Lloyd-Jones D.M. Adams R.J. Berry J.D. Brown T.M. Carnethon M.R. Dai S. de Simone G. Ford E.S. Fox C.S. Fullerton H.J. Gillespie C. Greenlund K.J. Hailpern S.M. Heit J.A. Ho P.M. Howard V.J. Kissela B.M. Kittner S.J. Lackland D.T. Lichtman J.H. Lisabeth L.D. Makuc D.M. Marcus G.M. Marelli A. Matchar D.B. McDermott M.M. Meigs J.B. Moy C.S. Mozaffarian D. Mussolino M.E. Nichol G. Paynter N.P. Rosamond W.D. Sorlie P.D. Stafford R.S. Turan T.N. Turner M.B. Wong N.D. Wylie-Rosett J. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation 2011 123 4 e18 e209 10.1161/CIR.0b013e3182009701 21160056
    [Google Scholar]
  44. Anker D. Santos-Eggimann B. Santschi V. Del Giovane C. Wolfson C. Streit S. Rodondi N. Chiolero A. Screening and treatment of hypertension in older adults: less is more? Public Health Rev. 2018 39 1 26 10.1186/s40985‑018‑0101‑z 30186660
    [Google Scholar]
  45. Williamson J.D. Supiano M.A. Applegate W.B. Berlowitz D.R. Campbell R.C. Chertow G.M. Fine L.J. Haley W.E. Hawfield A.T. Ix J.H. Kitzman D.W. Kostis J.B. Krousel-Wood M.A. Launer L.J. Oparil S. Rodriguez C.J. Roumie C.L. Shorr R.I. Sink K.M. Wadley V.G. Whelton P.K. Whittle J. Woolard N.F. Wright J.T. Pajewski N.M. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged≥ 75 years: a randomized clinical trial. JAMA 2016 315 24 2673 2682 10.1001/jama.2016.7050 27195814
    [Google Scholar]
  46. Bundy J.D. Li C. Stuchlik P. Bu X. Kelly T.N. Mills K.T. He H. Chen J. Whelton P.K. He J. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol. 2017 2 7 775 781 10.1001/jamacardio.2017.1421 28564682
    [Google Scholar]
  47. Qaseem A. Wilt T.J. Rich R. Humphrey L.L. Frost J. Forciea M.A. Fitterman N. Barry M.J. Horwitch C.A. Iorio A. McLean R.M. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann. Intern. Med. 2017 166 6 430 437 10.7326/M16‑1785 28135725
    [Google Scholar]
  48. Ogurtsova K. Guariguata L. Barengo N.C. Ruiz P.L.D. Sacre J.W. Karuranga S. Sun H. Boyko E.J. Magliano D.J. IDF diabetes Atlas: Global estimates of undiagnosed diabetes in adults for 2021. Diabetes Res. Clin. Pract. 2022 183 109118 10.1016/j.diabres.2021.109118 34883189
    [Google Scholar]
  49. Zhang L. Li X. Wolfe C.D.A. O’Connell M.D.L. Wang Y. Diabetes as an independent risk factor for stroke recurrence in ischemic stroke patients: an updated meta-analysis. Neuroepidemiology 2021 55 6 427 435 10.1159/000519327 34673640
    [Google Scholar]
  50. Lo J.W. Crawford J.D. Samaras K. Desmond D.W. Köhler S. Staals J. Verhey F.R.J. Bae H.J. Lee K.J. Kim B.J. Bordet R. Cordonnier C. Dondaine T. Mendyk A.M. Lee B.C. Yu K.H. Lim J.S. Kandiah N. Chander R.J. Yatawara C. Lipnicki D.M. Sachdev P.S. Association of prediabetes and type 2 diabetes with cognitive function after stroke: a STROKOG collaboration study. Stroke 2020 51 6 1640 1646 10.1161/STROKEAHA.119.028428 32404039
    [Google Scholar]
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Utilization Trends and Outcomes of Alteplase in Acute Cerebral Ischemia among Patients with Hypertension or Diabetes: A Tertiary Care Experience from Southern Punjab
Bentham Science Publishers ; https://doi.org/10.2174/011871529X381588250612061045
/content/journals/chddt/10.2174/011871529X381588250612061045
/content/journals/chddt/10.2174/011871529X381588250612061045
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  • Article Type:     Research Article
Keywords: diabetes ; cerebral embolism ; Hypertension ; cerebralischemia ; thrombolytic agent ; alteplase ; hemiplegia ; acute stroke

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