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 h 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 h was 81.1 %, (95 % CI 74.5, 87.8, p < 0.0001, I²=99.99 %). The high heterogeneity was due to within-country (I²_{Level 3} = 55.4 %) and between-country heterogeneity (I²_{Level 2} = 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, I²=100 %) and high-income countries (HIC) - 86.8 %, (95 % CI 81.2, 92.3, p < 0.01, I²=99.7 %) nor any difference between contemporary studies (2008 and later) - 86.5 %, (95 % CI 82.3, 90.8, p < 0.01, I²=100 %) - and studies published before 2008 - 69.9 %, (95 % CI 57.4, 82.4, p < 0.01, I²=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 h 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.