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Door-to-Needle Time and 1-Year Mortality in Ischemic Stroke
Quick Takes
- It has been shown that earlier IV tPA administration improves in-hospital and 90-day clinical outcomes after acute ischemic stroke.
- In this large, registry-based study of patients ages ≥65 years, earlier IV tPA treatment was associated with better long-term (1-year) clinical outcomes.
- These findings provide further support for hospital, community, and nationwide efforts to shorten door-to-needle times for patients presenting with acute ischemic stroke.
Study Questions:
While earlier intravenous (IV) tissue plasminogen activator (tPA) administration is known to improve in-hospital and 90-day clinical outcomes after acute ischemic stroke, what is the relationship between earlier IV tPA administration and 1-year clinical outcomes?
Methods:
This is a registry-based study using the Get With The Guidelines (GWTG)-Stroke database of acute ischemic stroke patients treated at participating hospitals. The included cohort consists of patients ages ≥65 years who were treated with IV tPA between 2006 and 2016. Patients who received mechanical thrombectomy were excluded. Patient GWTG records were linked to Medicare claims data to obtain 1-year outcomes. The primary outcomes include 1-year all-cause mortality, 1-year all-cause readmission, and the composite of both. The patient-level variables included in the fully adjusted model are age, sex, race/ethnicity, vascular risk factors, arrival by emergency medical service yes/no, treatment during on- versus off-hours, and National Institutes of Health stroke scale score.
Results:
The analyzed cohort consisted of 61,426 patients. Patients who received IV tPA after 60 minutes of hospital arrival compared to within 60 minutes of hospital arrival had significantly higher 1-year all-cause mortality (35.8% vs. 32.1%; adjusted hazard ratio [aHR], 1.11; 95% confidence interval [CI], 1.07-1.14), higher 1-year all-cause readmission (41.3% vs. 39.1%; aHR, 1.07; 95% CI, 0.04-1.10), and higher combined all-cause mortality or readmission (56.8% vs. 53.1%; aHR ,1.08; 95% CI, 1.05-1.10). Every 15-minute increase in door-to-needle time was associated with higher 1-year all-cause readmission (aHR, 1.02; 95% CI, 1.01-1.03) and higher 1-year all-cause mortality or readmission (aHR, 1.02; 95% CI, 1.01-1.03). Every 15-minute increase in door-to-needle time was associated with higher 1-year all-cause mortality (aHR, 1.04; 95% CI, 1.02-1.05) for door-to-needle time within 90 minutes of arrival. This association was not observed for patients treated beyond 90 minutes of hospital arrival.
Conclusions:
For older acute ischemic stroke patients treated with IV tPA in GWTG-Stroke hospitals, a shorter door-to-needle time for IV tPA administration was associated with lower 1-year all-cause mortality and 1-year all-cause readmission.
Perspective:
Stroke thrombolytic trials have repeatedly shown that shorter door-to-needle times are associated with better in-hospital and 90-day clinical outcomes. This study suggests that shorter door-to-needle times are also associated with better longer-term (i.e., 1-year) outcomes in an older population. There is no compelling reason to believe that a similar association would not be seen for younger patients at 1 year. These findings provide further support for hospital, community, and nationwide efforts to shorten door-to-needle times for acute ischemic stroke patients.
Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Cardiac Surgery and Arrhythmias, Lipid Metabolism
Keywords: Brain Ischemia, Emergency Medical Services, Fibrinolytic Agents, Patient Readmission, Risk Factors, Secondary Prevention, Stroke, Thrombectomy, Tissue Plasminogen Activator, Vascular Diseases
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