The relationship between pre-stroke depression and stroke treatment remains unclear. Patients with depression are more likely to suffer a stroke than those without depression in the population [1]. Roughly 7% of the United States’ population is diagnosed with major depressive disorder each year [2]. It is necessary to understand the link between pre-stroke depression and rtPA administration. Thrombolysis therapy is the gold standard in acute ischemic stroke treatment, and it remains significantly underused. This study aims to examine the clinical risk factors associated with tPAinclusion and exclusion in acute ischemic stroke populations with depression. Understanding the clinical risk factors associated with rtPA inclusion and exclusion in patients with pre-stroke depression will help in the development of treatment protocols.

Introduction

Methods

Binary logistic regression was used to determine risk factors that are associated with tPA use in a telestroke setting in patients with depression. Multivariate analysis using a stepwise conditional logistic regression with P<0.05 was performed to determine demographic and clinical characteristics associated with exclusion from rtPAadministration in the total study population as well as in the telestroke subgroup and non-telestroke subgroup. We checked for multicollinearity and interactions among independent variables using Hosmer-Lemeshow test. We presented all results for our multivariate analysis as odds ratio estimates at 95% confidence interval and results were considered significant at P<0.05.

v In the acute ischemic stroke populationwith depression and telestroke, INR wasmarginally involved with the rtPAinclusion or exclusion paradigm.

v In the acute ischemic stroke populationwith a diagnosis of depression and non-telestroke increasing age wasassociated with rtPA inclusion.

v Caucasian race, systolic blood pressure,and direct admission were associatedwith rtPA exclusion in the population withdepression history and non-telestroke.

v Patients with depression treated withouttelestroke who had a higher NIHSSscore were more likely to receive rtPA.

v In patients treated in the non-telestrokesetting, lower triglycerides and lowerserum creatinine were likely to lead tortPA inclusion.

References

Acute Ischemic Stroke with Depression Telestroke

Acute Ischemic Stroke with Depression Non-Telestroke

P-Value

Characteristic (N=62) (N=122)Age Group: No. (%)

<50 13 (21.0) 22 (18.0) 0.74850-59 13 (21.0) 31 (25.4)60-69 17 (27.4) 27 (22.1)70-79 9 (14.5) 25 (20.5)>=80 10 (16.1) 17 (13.9)Mean ± SD 61.68 ± 15.7 62.66 ± 14.68 0.674

Race: No (%)White 56 (90.3) 106 (86.9) 0.616Black 5 (8.1) 15 (12.3)Other 1 (1.6) 1 (0.8)

Gender: No. (%)Female 37 (59.7) 90 (73.8) 0.051Male 25 (40.3) 32 (26.2)

Hispanic Ethnicity: No. (%) 1 (1.6) 1 (0.8) 0.624BMI: Mean ± SD 32.49 ± 8.09 29.54 ± 7.43 0.017*b

Medical History: No. (%)Atrial Fib 3 (4.8) 21 (17.2) 0.018*a

Coronary Artery Disease 22 (35.5) 34 (27.9) 0.289Carotid Artery Stenosis 4 (6.5) 3 (2.5) 0.181Diabetes 31 (50.0) 48 (39.3) 0.168Drugs or Alcohol 2 (3.2) 11 (9.0) 0.147Dyslipidemia 42 (67.7) 67 (54.9) 0.094Stroke Family History 13 (21.0) 19 (15.6) 0.362Heart Failure 6 (9.7) 13 (10.7) 0.837Hormonal Replacement Therapy 3 (4.8) 8 (6.6) 0.642Hypertension 55 (88.7) 101 (82.8) 0.290Migraine 1 (1.6) 12 (9.8) 0.040*a

Obesity 47 (75.8) 83 (68.0) 0.274Previous Stroke 17 (27.4) 32 (26.2) 0.863Previous TIA (> 24 hours) 12 (19.4) 4 (3.3) <0.001*a

Prosthetic Heart Valve 0 (0.0) 2 (1.6) 0.311Peripheral Vascular Disease 9 (14.5) 8 (6.6) 0.078Chronic Renal Disease 6 (9.7) 13 (10.7) 0.837Sleep Apnea 7 (11.3) 14 (11.5) 0.970Smoker 14 (22.6) 31 (25.4) 0.673

Medication History: No (%)HTN medication 49 (79.0) 84 (68.9) 0.145Cholesterol Reducer 30 (48.4) 61 (50.0) 0.836Diabetes medication 25 (40.3) 39 (32.0) 0.261Antidepressant 47 (75.8) 95 (77.9) 0.753

Initial NIHSS Score: No (%)0-9 47 (79.7) 60 (55.6) 0.007*a

10-14 1 (1.7) 13 (12.0)15-20 9 (15.3) 22 (20.4)21-25 2 (3.4) 13 (12.0)Mean ± SD 7.41 ± 7.55 10.04 ± 9.1 0.043*b

Lab values: Mean ± SDTotal cholesterol 170.5 ± 41.89 173.94 ± 44.16 0.623Triglycerides 161.88 ± 89.71 163.81 ± 110.34 0.908HDL 39.9 ± 13.17 41.83 ± 12.81 0.356LDL 101.2 ± 34.48 105.13 ± 38.1 0.509Lipids 6.47 ± 1.6 7.14 ± 8.53 0.555Blood Glucose 145.75 ± 84.68 154.85 ± 94.13 0.525Serum Creatinine 1.04 ± 0.33 1.33 ± 1.38 0.030*b

INR 1.04 ± 0.25 1.13 ± 0.32 0.101Vital Signs: Mean ± SD

Heart Rate 78.07 ± 14.9 82.46 ± 17.61 0.098Blood Pressure Systolic 146.57 ± 24.29 148.08 ± 24.86 0.697Blood Pressure Diastolic 79.53 ± 18.97 79.74 ± 19.51 0.947

Ambulation Status Prior to Event: No. (%)Ambulate Independently 59 (95.2) 111 (91.0) 0.590Ambulate with Assistance 1 (1.6) 4 (3.3)Unable to Ambulate 1 (1.6) 1 (0.8)Not Documented 1 (1.6) 6 (4.9)

Ambulation Status on Admission: No. (%)Ambulate Independently 22 (35.5) 28 (23.0) 0.044*a

Ambulate with Assistance 13 (21.0) 39 (32.0)Unable to Ambulate 16 (25.8) 44 (36.1)Not Documented 11 (17.7) 11 (9.0)

Ambulation Status on Discharge: No. (%)Ambulate Independently 41 (66.1) 56 (45.9) 0.020*a

Ambulate with Assistance 12 (19.4) 35 (28.7)Unable to Ambulate 9 (14.5) 21 (17.2)Not Documented 0 (0) 10 (8.2)

First Care Received: No. (%)Emergency Department 21 (34.4) 70 (57.4) 0.003*a

Direct Admission 40 (65.6) 52 (42.6)rtPA Administration 49 (79.0) 31 (25.4) <0.001*a

Improved Ambulation 27 (43.5) 46 (41.1) 0.751

Acute Ischemic Stroke with Depression and Telestroke

Acute Ischemic Stroke with Depression and Non-

TelestrokeNo rtPA rtPA P-

ValueNo rtPA rtPA P-

ValueCharacteristic (N=13) (N=49) (N=91) (N=31)Age Group: No. (%)

<50 years 2 (15.4) 11 (22.4) 0.204 19 (20.9) 3 (9.7) 0.14450-59 2 (15.4) 11 (22.4) 24 (26.4) 7 (22.6)60-69 7 (53.8) 10 (20.4) 20 (22.0) 7 (22.6)70-79 1 (7.7) 8 (16.3) 14 (15.4) 11 (35.5)>=80 1 (7.7) 9 (18.4) 14 (15.4) 3 (9.7)Age Mean ± SD 61.69 ± 12 61.67 ± 16.65 0.996 61.62 ± 15.27 65.74 ± 12.52 0.178

Race: No (%)White 13 (100.0) 43 (87.8) 0.414 84 (92.3) 22 (71.0) 0.004*a

Black 0 (0.0) 5 (10.2) 6 (6.6) 9 (29.0)Other 0 (0.0) 1 (2.0) 1 (1.1) 0 (0.0)

Gender: No. (%)Female 7 (53.8) 30 (61.2) 0.630 65 (71.4) 25 (80.6) 0.314Male 6 (46.2) 19 (38.8) 26 (28.6) 6 (19.4)

Hispanic Ethnicity: No. (%) 0 (0.0) 1 (2.0) 0.604 1 (1.1) 0 (0.0) 0.558BMI: Mean ± SD 31.51 ± 6.13 32.72 ± 8.53 0.659 29.52 ± 7.32 29.58 ± 7.85 0.968Medical History: No. (%)

Atrial Fib 0 (0.0) 3 (6.1) 0.360 16 (17.6) 5 (16.1) 0.853Coronary Artery Disease 5 (38.5) 17 (34.7) 0.801 26 (28.6) 8 (25.8) 0.767Carotid Artery Stenosis 0 (0.0) 4 (8.4) 0.287 2 (2.2) 1 (3.2) 0.750Diabetes 7 (53.8) 24 (49.0) 0.755 37 (40.7) 11 (35.5) 0.610Drugs or Alcohol 0 (0.0) 2 (4.1) 0.459 9 (9.9) 2 (6.5) 0.564Dyslipidemia 10 (76.9) 32 (65.3) 0.426 49 (53.8) 18 (58.1) 0.684Stroke Family History 4 (30.8) 9 (18.4) 0.329 13 (14.3) 6 (19.4) 0.501Heart Failure 1 (7.7) 5 (10.2) 0.785 11 (12.1) 2 (6.5) 0.380Hormonal Replacement Therapy 0 (0.0) 3 (6.1) 0.360 7 (7.7) 1 (3.2) 0.386Hypertension 11 (84.6) 44 (89.8) 0.600 74 (81.3) 27 (87.1) 0.462Migraine 0 (0.0) 1 (2.0) 0.604 9 (9.9) 3 (9.7) 0.973Obesity 9 (69.2) 38 (77.6) 0.533 63 (69.2) 20 (64.5) 0.627Previous Stroke 3 (23.1) 14 (28.6) 0.693 23 (25.3) 9 (29.0) 0.681Previous TIA (>24 hours) 2 (15.4) 10 (20.4) 0.684 2 (2.2) 2 (6.5) 0.251Prosthetic Heart Valve 0 (0.0) 0 (0.) 2 (2.2) 0 (0.0) 0.405Peripheral Vascular Disease 0 (0.0) 9 (18.4) 0.95 8 (8.8) 0 (0.0) 0.088Chronic Renal Disease 0 (0.0) 6 (12.2) 0.184 11 (12.1) 2 (6.5) 0.380Sleep Apnea 2 (15.4) 5 (10.2) 0.600 7 (7.7) 7 (22.6) 0.025*a

Smoker 3 (23.1) 11 (22.4) 0.962 22 (24.2) 9 (29.0) 0.592Medication History: No (%)

HTN medication 10 (76.9) 39 (79.6) 0.834 59 (64.8) 25 (80.6) 0.101Cholesterol Reducer 6 (42.6) 24 (49.0) 0.856 45 (49.5) 16 (51.6) 0.835Diabetes medication 5 (38.5) 20 (40.8) 0.878 30 (33.0) 9 (29.0) 0.685Antidepressant 10 (76.9) 37 (75.5) 0.916 67 (73.6) 28 (90.3) 0.053

Initial NIHSS Score: No (%)0-9 9 (75.0) 38 (80.9) 0.705 51 (65.4) 9 (30.0) 0.011*a

10-14 0 (0.0) 1 (2.1) 7 (9.0) 6 (20.0)15-20 2 (16.7) 7 (14.9) 13 (16.7) 9 (30.0)21-25 1 (8.3) 1 (2.1) 7 (9.0) 6 (20.0)NIHSS Score Mean ± SD 6.83 ± 7.74 7.55 ± 7.58 0.771 8.75 ± 9.28 13.48 ± 7.69 0.013*b

Lab values: Mean ± SDTotal cholesterol 167.42 ± 40.79 171.27 ± 42.54 0.778 177.81 ± 44.88 163.38 ± 41.05 0.133Triglycerides

180.42 ± 64.6 157.25 ± 94.960.428 177.29 ±

119.38 127.1 ± 70.130.036*b

HDL 38.33 ± 8.35 40.29 ± 14.16 0.649 41.79 ± 13.35 41.93 ± 11.45 0.961LDL 98 ± 31.02 102 ± 35.55 0.723 106.92 ± 39.26 100.53 ± 35.15 0.439Lipids 6.74 ± 2.03 6.4 ± 1.49 0.515 7.41 ± 9.98 6.39 ± 1.38 0.579Blood Glucose 165.31 ± 116.27 140.46 ± 74.62 0.352 149.43 ± 78.98 170.77 ± 129.13 0.277Serum Creatinine 0.98 ± 0.28 1.05 ± 0.34 0.521 1.43 ± 1.57 1.04 ± 0.43 0.037*b

INR 1.19 ± 0.48 0.99 ± 0.09 0.226 1.16 ± 0.37 1.06 ± 0.11 0.056Vital Signs: Mean ± SD

Heart Rate 79.77 ± 20.58 77.6 ± 13.17 0.646 82.65 ± 17.25 81.9 ± 18.91 0.840Blood Pressure Systolic 141.85 ± 22.58 147.87 ± 24.81 0.433 149.95 ± 24.1 142.61 ± 26.61 0.157Blood Pressure Diastolic 76.69 ± 9.79 80.32 ± 20.82 0.378 80.21 ± 18.31 78.35 ± 22.96 0.650

Ambulation Status Prior to Event: No. (%)

Ambulate Independently 13 (100.0) 46 (93.9) 0.841 82 (90.1) 29 (93.5) 0.893Ambulate with Assistance 0 (0.0) 1 (2.0) 3 (3.3) 1 (3.2)Unable to Ambulate 0 (0.0) 1 (2.0) 1 (1.1) 0 (0.0)Not Documented 0 (0.0) 1 (2.0) 5 (5.5) 1 (3.2)

Ambulation Status on Admission: No. (%)

Ambulate Independently 5 (38.5) 17 (34.7) 0.276 27 (29.7) 1 (3.2) 0.011*a

Ambulate with Assistance 4 (30.8) 9 (18.4) 29 (31.9) 10 (32.3)Unable to Ambulate 4 (30.8) 12 (24.5) 27 (29.7) 17 (54.8)Not Documented 0 (0.0) 11 (22.4) 8 (8.8) 3 (9.7)

Ambulation Status on Discharge: No. (%)

Ambulate Independently 9 (69.2) 32 (65.3) 0.716 40 (44.0) 16 (51.6) 0.897Ambulate with Assistance 3 (23.1) 9 (18.4) 27 (29.7) 8 (25.8)Unable to Ambulate 1 (7.7) 8 (16.3) 16 (17.6) 5 (16.1)Not Documented 0 (0.0) 0 (0.0) 8 (8.8) 2 (6.5)

First Care Received: No. (%)Emergency Department 6 (46.2) 15 (31.3) 0.316 41 (45.1) 29 (93.5) <0.001*a

Direct Admission 7 (53.8) 33 (68.8) 50 (54.9) 2 (6.5)Improved Ambulation 5 (38.5) 22 (44.9) 0.677 26 (31.3) 20 (69.0) <0.001*a

Table 1. Demographic and clinical characteristics of ischemic stroke patients with depression in telestroke or non-telestroke population. Results for continuous variables are presented as Mean ± SD, while discrete data are presented as percentage frequency. Pearson’s Chi-Square is used to compare differences between demographic and clinical characteristics in groups with a history of depression depending on telestroke.

Table 2. Demographic and clinical characteristics of receiving rtPA in ischemic stroke patients with depression in telestroke or non-telestroke population. Results for continuous variables are presented as Mean ± SD, while discrete data are presented as percentage frequency. Pearson’s Chi-Square is used to compare differences between demographic and clinical characteristics in groups with a history of depression and either telestroke or non-telestroke on rtPA.

References1. Dong, Jia-Yi, et al. “Depression and Risk of Stroke.” Stroke, vol. 43, no. 1, 2012, pp. 32–37.,

doi:10.1161/strokeaha.111.630871.2. “Facts & Statistics.” Anxiety and Depression Association of America, ADAA, adaa.org/about-

adaa/press-room/facts-statistics.

Summary of Results

Results

Associated with rtPAexclusion

Associated with rtPAinclusion

Criteria For Tissue Plasminogen Activator In Patients With Pre-Stroke Depression In Telestroke Settings

Rachel Michelle Shugart, Nicolas Poupore, Robyn Moraney, Mandy Tate, and Thomas I. Nathaniel, PhDUniversity of South Carolina School of Medicine-Greenville, Greenville, SC 29605, USA

This study was funded by the Fullerton Foundation Grant.