Timeliness of Tissue-Type Plasminogen Activator Therapy in Acute Ischemic Stroke: Patient Characteristics, Hospital Factors, and Outcomes Associated With Door-to-Needle Times Within 60 Minutes

Study Questions:

What were the presenting characteristics of acute ischemic stroke patients treated with intravenous tissue-type plasminogen activator (tPA) within 3 hours of symptom onset in whom a door-to-needle time ≤60 minutes was achieved, hospital-level variation in door-to-needle times, in-hospital clinical outcomes, and temporal trends in timely thrombolytic care?

Methods:

Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1,082 hospitals participating in the Get With the Guidelines–Stroke Program from April 1, 2003, to September 30, 2009, were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. GEE logistic regression models were developed to determine temporal trends in door-to-needle times ≤60 minutes, with adjustment for patient and hospital characteristics.

Results:

Among 25,504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6,790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60-minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 (p < 0.0001). Despite similar stroke severity, in-hospital mortality was lower (adjusted odds ratio, 0.78; 95% confidence interval, 0.69-0.90; p < 0.0003), and symptomatic intracranial hemorrhage was less frequent (4.7% vs. 5.6%; p < 0.0017) for patients with door-to-needle times ≤60 minutes compared with patients with door-to-needle times >60 minutes.

Conclusions:

The authors concluded that less than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years.

Perspective:

This analysis demonstrates that only a minority of patients with acute ischemic stroke are treated with intravenous tPA within 60 minutes of arrival. Older patients, black patients, women, and those with less severe strokes or arriving during off-hours were particularly less likely to receive timely care. Furthermore, this study reports only modest improvements in the timely administration of tPA over calendar time or duration of program participation. Given the slow progress in achieving faster door-to-needle times and the large treatment gap, these data support the need for a collaborative national campaign and targeted regional initiatives to improve timely treatment with intravenous tPA and optimize clinical benefit.

Clinical Topics: Dyslipidemia, Lipid Metabolism, Novel Agents

Keywords: Stroke, Plasminogen Activators, Fibrinolytic Agents, Tissue Plasminogen Activator, Needles


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