Abstract TP53: How Do Physicians Approach Intravenous Alteplase Treatment in Acute Ischemic Stroke Patients? Insights From Unmask Evt, an International Multidisciplinary Study

Background and Purpose: With increasing use of endovascular therapy (EVT), physician attitudes towards intravenous alteplase in EVT-eligible patients may be changing. We explored current intravenous alteplase treatment practices of physicians and compared how their current treatment practice differs to an assumed ideal environment. Methods: In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 of 22 case-scenarios, among them 14 with guideline-based recommendation for intravenous alteplase treatment, and asked how they would treat the patient: A) under their current local resources and B) under assumed ideal conditions, i.e. with no external restraints. Answer options were 1) anticoagulation/antiplatelet therapy, 2) EVT, 3) EVT plus intravenous alteplase and 4) intravenous alteplase . Decision rates were calculated and clustered multivariable regression analysis was performed to determine adjusted measures of effect size. Results: Physicians favored intravenous alteplase in 82.0% (85.0% in level 1A scenarios and 76.5% in level 2B scenarios) under current local resources and in 79.3% (82.4% in level 1A scenarios and 73.7% in level 2B scenarios) under assumed ideal conditions (difference between current and ideal rates: p<0.001 respectively). This discrepancy was driven by physicians who favored EVT alone rather than EVT in combination with intravenous alteplase . Interventional neuroradiologists favored dropping intravenous alteplase most often (6.28%), and this specialty was associated with greater odds of dropping intravenous alteplase (OR 1.97, p=.041). Conclusion: Participants of this survey currently favoured treating slightly more patients with intravenous alteplase than they would like to treat in an ideal environment.