Beyond FAST: Evaluating the Impact of Expanded Stroke Criteria on Emergency Response

Abstract Background In Ireland, the ACT FAST campaign has been a central strategy to raise public awareness of stroke symptoms, with initiatives in 2010, 2015, and 2023. While the FAST (Face, Arm, Speech, Time) acronym targets core anterior circulation symptoms, the expanded BE-FAST criteria include Balance and Eye symptoms to improve detection of posterior circulation strokes. This study evaluates whether expanding symptom recognition improves timely hospital presentation and treatment access. Methods A retrospective review of a stroke register at a single Irish centre was conducted, analysing patients who presented between January and December 2022. Data collected included demographics, mode of arrival (self vs ambulance), symptom type (FAST or BE-FAST), and time from symptom onset to hospital arrival. Symptom classification was based on clinical documentation. Results Of 316 stroke patients, 74.4% were FAST-positive and 87% were BE-FAST-positive. While BE-FAST improved overall sensitivity, FAST-positive patients were significantly more likely to arrive by ambulance (p = 0.035). Only speech symptoms were independently associated with both earlier presentation and a higher likelihood of receiving endovascular treatment (EVT) (p = 0.021). No significant time-to-treatment benefit was found for BE-FAST-positive patients compared to FAST-positive alone. Conclusion Although the BE-FAST criteria identify more patients with stroke symptoms, they do not appear to meaningfully enhance time-to-treatment or increase ambulance use. Speech symptoms remain the most predictive of early arrival and intervention. These findings suggest that while broader symptom messaging increases sensitivity, continued emphasis on the core FAST symptoms—especially speech—may be more effective in prompting timely presentation and treatment.