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component of acute management. In general, the medical or surgical interventions administered to prevent recurrent stroke are similar to those prescribed to patients with recent transient ischemic attacks or to other high-risk persons. The reader is referred to another recent statement that addresses the management of risk factors, the prescription of antithrombotic medications, and the use of surgical or endovascular interventions to prevent recurrent stroke.4 In writing these guidelines, the panel applied the rules of evidence and the formulation of strength of recommendations used by other panels of the American Heart Association (AHA)4 (see the Figure and Table 1). The data were collected through a systematic review of the literature. Because of the wide scope of the guidelines, the members of the panel were assigned primary reviews for individual sections. Then the panel assessed the complete guidelines. If the panel concluded that data supported or did not support the use of a specific intervention, appropriate recommendations were made. In some cases in which definitive data were not available, no specific recommendation was made. Italics indicate recommendations that have been changed or added since the publication of the previous guideline. In other instances, supporting evidence based on clinical trial research was not available for a specific intervention, but the panel has made a specific recommendation on the basis of pathophysiological reasoning and expert practice experience. For many of these interventions, it is unlikely that randomized trials will ever be performed. An example is the recommendation to perform endotracheal intubation to protect the airway in a comatose patient.. Applying classification of recommendations and level of evidence.TABLE 1. Definition of Classes and Levels of Evidence Used in AHA Recommendations I. PREHOSPITAL MANAGEMENT AND FIELD TREATMENT Recent data indicate that 29% to 65% of patients with signs or symptoms of acute stroke access their initial medical care via local EMS which confirms the role of EMS in the chain of survival.5–13 Notably, an estimated 19% to 60% of stroke patients present within 3 hours of stroke and 14% to 32% of those arrive within 2 hours of symptom onset. Although just over half of all stroke patients use EMS access to health care, those who do utilize EMS comprise the majority of patients presenting within EMS activation appears to be a function primarily of individuals other than the patient, with one report indicating that a family member, paid caregiver, coworker, or other bystander accounted for 62% to 95% of 9-1-1 activation calls.6,9 In addition to bystander recognition of a problem, other reported predictors of EMS use by stroke patients include stroke severity,17 presence of intracranial hemorrhage,9,18 age,9,18 sense of urgency,9 unemployment,6 and race (black).18 The benefits of EMS activation by patients with stroke symptoms appear to occur in both the prehospital and in-hospital settings. Hospital arrival is faster for patients who use EMS/9-1-1 as their initial medical contact than for those who contact their primary physician or hospital directly18 or a primary care site.19 Not surprisingly, EMS use is strongly associated with shorter time periods from symptom onset to hospital arrival, although this may reflect a greater sense of urgency on the patient’s or bystander’s part rather than reduced transport time.8,9,12 Similarly, EMS use is strongly associated with decreased time to initial physician examination,9,10,13,20 initial computed tomography (CT) imaging,9,10,12 and neurological evaluation.9 On the basis of the aforementioned information, communities should encourage 9-1-1 activation and use for patients with symptoms of acute stroke. Data from the TLL Temple Foundation Stroke Project controlled trial indicate that educational interventions on stroke identification and management targeting patients, EMS, hospitals, and community physicians increased thrombolytic use in patients with ischemic stroke from 2.21% to 8.65% as compared with communities that did not have such programs, which saw only a 0.06% increase. For patients with ischemic stroke who were eligible for thrombolytic therapy, rates of tissue-type plasminogen activator (tPA) use increased from 14% to 52% in intervention communities. The benefit from this aggressive intervention program was sustained at 6 months after intervention.21,22 A. EMS Assessment EMS assessment begins with the initial 9-1-1 contact The role of the dispatch system is to ensure immediate triage and dispatch of appropriate EMS providers when acute stroke is suspected by either the caller or the dispatcher.23 Data from 2 systems indicate that dispatchers correctly suspected or identified 52% of patients ultimately proven to have had a stroke on initial telephone evaluation.7,24 These data imply that educational programs should be aimed at dispatchers to increase their awareness of stroke symptoms. Stroke should be given a priority dispatch similar to that for acute myocardial infarction or trauma.25 After ambulance arrival on the scene, EMS providers should obtain a focused history and patient assessment, provide necessary stabilization and treatment, and transport immediately to the closest, most appropriate facility The word appropriate is key because it means that an ambulance may bypass a hospital that does not have the resources or institutional commitment to treat patients with stroke if a more appropriate hospital is available within a reasonable transport interval. Advance notice to the receiving emergency department (ED) of the impending arrival of a potential stroke patient, along with information on comorbid conditions and estimated time of symptom onset, will speed the
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