Time-Sensitive Treatment Goals for Acute Ischemic Stroke and Acute Myocardial Infarction

Acute Ischemic Stroke: Door-to-Needle Time Goals

The American Heart Association/American Stroke Association establishes a Class I recommendation that door-to-needle (DTN) times should be ≤60 minutes in ≥50% of acute ischemic stroke patients treated with IV alteplase 1, 3
A more aggressive secondary goal of achieving DTN times ≤45 minutes in ≥50% of patients is reasonable (Class IIb recommendation) 1, 3
The Canadian Stroke Best Practice Recommendations set an even more ambitious target: DTN time <60 minutes in 90% of treated patients, with a median DTN time of 30 minutes 4
Every 15-minute reduction in door-to-needle time translates to a 5% lower odds of in-hospital mortality (adjusted OR 0.95, 95% CI 0.92-0.98) 5
IV alteplase should be administered within 3 hours of symptom onset (Class I, Level A recommendation), with extension to 4.5 hours for selected patients (Class I/IIa, Level B recommendation) 1, 6, 7
Treatment beyond 4.5 hours requires consultation with a stroke specialist and remains investigational 4

For patients transported by EMS to a PCI-capable hospital, the goal is EMS arrival-to-balloon time ≤90 minutes 2, 8
For patients who self-transport to a PCI-capable hospital, the door-to-balloon time goal is ≤90 minutes 2, 8
For patients transported to non-PCI-capable hospitals where fibrinolysis is indicated, the door-to-needle time goal is ≤30 minutes 2, 8
If EMS has fibrinolytic capability, prehospital fibrinolysis should be initiated within 30 minutes of EMS arrival on scene 2, 8
The overarching goal is to keep total ischemic time within 120 minutes (ideally within 60 minutes) from symptom onset to initiation of reperfusion treatment 8

EMS prenotification is essential and associated with shorter door-to-imaging times (26 vs 31 minutes), shorter DTN times (78 vs 80 minutes), and increased likelihood of treatment within 3 hours 1
Multicomponent quality improvement initiatives including ED education and multidisciplinary teams with neurological expertise are strongly recommended (Class I, Level A) 1, 3
Prehospital 12-lead ECG programs by EMS providing advanced life support are underutilized but effective strategies for improving systems of care 8
Transfer protocols must be in place for arranging rescue PCI when fibrinolysis is unsuccessful 8

Do not perform extensive diagnostic workup that delays treatment—brain imaging to rule out hemorrhage is the only essential test before alteplase administration 9, 10
Do not administer aspirin or other antithrombotic agents before brain imaging rules out hemorrhagic stroke 9
Do not aggressively lower blood pressure in suspected ischemic stroke patients who may be candidates for thrombolytic therapy unless BP exceeds specific thresholds (systolic >220 mmHg or diastolic >120 mmHg) 9, 10
For AMI, the emphasis on primary PCI should not obscure the importance of fibrinolytic therapy when PCI cannot be achieved within the 90-minute goal 8