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Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke
Study Questions:
What is the degree to which onset-to-treatment (OTT) time is associated with outcome among patients with acute ischemic stroke treated with intravenous tissue plasminogen activator (tPA)?
Methods:
Data were analyzed from 58,353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset in 1,395 hospitals participating in the Get With The Guidelines-Stroke Program, April 2003 to March 2012. The main outcomes measure was relationship between OTT time and in-hospital mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination.
Results:
Among the 58,353 tPA-treated patients, median age was 72 years, 50.3% were women, median OTT time was 144 minutes (interquartile range, 115-170), 9.3% (5,404) had OTT time of 0-90 minutes, 77.2% (45,029) had OTT time of 91-180 minutes, and 13.6% (7,920) had OTT time of 181-270 minutes. Median pretreatment National Institutes of Health Stroke Scale documented in 87.7% of patients was 11 (interquartile range, 6-17). Patient factors most strongly associated with shorter OTT included greater stroke severity (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.5-3.1 per 5-point increase), arrival by ambulance (OR, 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR, 4.6; 95% CI, 3.8-5.4). Overall, there were 5,142 (8.8%) in-hospital deaths, 2,873 (4.9%) patients had intracranial hemorrhage, 19,491 (33.4%) patients achieved independent ambulation at hospital discharge, and 22,541 (38.6%) patients were discharged to home. Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR, 0.96; 95% CI, 0.95-0.98; p < 0.001), reduced symptomatic intracranial hemorrhage (OR, 0.96; 95% CI, 0.95-0.98; p < 0.001), increased achievement of independent ambulation at discharge (OR, 1.04; 95% CI, 1.03-1.05; p < 0.001), and increased discharge to home (OR, 1.03; 95% CI, 1.02-1.04; p < 0.001).
Conclusions:
The authors concluded that earlier thrombolytic treatment was associated with reduced mortality and symptomatic intracranial hemorrhage, and higher rates of independent ambulation at discharge and discharge to home following acute ischemic stroke.
Perspective:
In this study of more than 50,000 patients with acute ischemic stroke treated with intravenous thrombolysis, treatment started more rapidly after symptom onset was associated with reduced in-hospital mortality and symptomatic intracranial hemorrhage and increased achievement of independent ambulation by discharge and discharge to home. These findings support intensive efforts with multipronged quality improvement programs to accelerate patient presentation and to streamline regional and hospital systems of acute stroke care to minimize/shorten OTT times.
Keywords: Time-to-Treatment, Walking, Stroke, Intracranial Hemorrhages, Hospital Mortality, Fibrinolytic Agents, Tissue Plasminogen Activator, Patient Discharge
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