Systematic review and meta-analysis of audits measuring antithrombotic therapy within forty-eight hours for ischemic stroke.

Background: Meta-analysis of clinical trials supports the use of early antithrombotic medication in ischemic stroke and transient ischemic attack. It is not known whether this therapy is delivered within the 85% threshold that is acceptable in North America's Get With The Guidelines stroke program.

Aim: to investigate the pooled proportion of patients receiving antiplatelet therapy within 48 hours of ischemic stroke.

Methods: PubMed to November 2022 was searched for studies reporting "stroke", "audit", "antithrombotic", "national" and "registry". Multilevel random effects meta-analysis was used to cluster studies by country.

Results: There were 45 studies describing 1,178,595 patients. The pooled proportion of patients receiving antithrombotic therapy within 48 hours was 81.1%, (95% CI 74.5, 87.8, p<0.0001, I=99.99%). The high heterogeneity was due to within-country (I=55.4%) and between-country heterogeneity (I=44.6%). There was no statistical significance (p=0.35) between low- to middle- income countries (LMIC) - 81.8%, (95% CI 76.1, 87.4, p<0.01, I=100%) and high-income countries (HIC) - 86.8%, (95% CI 81.2, 92.3, p<0.01, I=99.7%) nor any difference between contemporary studies (2008 and later) - 86.5%, (95% CI 82.3, 90.8, p<0.01, I=100%) - and studies published before 2008 - 69.9%, (95% CI 57.4, 82.4, p<0.01, I=99.7%). Sensitivity analysis showed no difference when excluding single centre studies, observations with n<500, or both. Meta-regression showed proportion of antiplatelet administration at 48 hours to increase significantly with subsequent year of publication (β=0.01, 95% CI 0.00, 0.02, p<0.05).

Conclusion: Our key finding is that the majority of countries do not yet provide early antiplatelet therapy at a level acceptable by Get With The Guidelines hospitals.