Earlier the better holds up in clinical practice for stroke thrombolysis
By Eleanor McDermid, Senior medwireNews Reporter
19 June 2013
JAMA 2013; 309: 2480–2488

medwireNews: Data from the Get With The Guidelines-Stroke initiative show the benefits of prompt thrombolysis in clinical practice.

Earlier treatment was associated with lower rates of symptomatic intracranial hemorrhage (ICH), as well as reduced mortality and higher rates of independent ambulation and discharge home, report Jeffrey Saver (University of California, Los Angeles, USA) and team in JAMA.

They note that the magnitude of the association between onset-to-treatment (OTT) time and functional outcomes observed in these data from 1395 US hospitals is similar to that achieved in randomized controlled trials of tissue plasminogen activator (tPA).

"The population of tPA-treated patients in the current study is more than 30 times larger than the pooled clinical trial sample and represents data from a more diverse set of hospitals, including more than one-quarter of all hospitals with an emergency department treating adults in the United States," says the team.

The median OTT for the 58,353 patients in the study was 144 minutes; 9.3% of patients were treated within 90 minutes of onset, 77.2% had an OTT between 91 and 180 minutes, and 13.6% were treated between 181 and 270 minutes.

Each 15-minute reduction in OTT time was associated with a significant 4% reduction in in-hospital mortality, a 4% reduction in symptomatic ICH, a 4% increase in the likelihood for being able to walk without another person's assistance at discharge, and a 3% increase in the chances for patients being able to return to their own home.

These associations were independent of multiple patient and hospital variables, but the researchers note that the strongest associations appeared in models that adjusted for baseline stroke severity.

"Since initial deficit severity is a dominant predictor of outcome from acute ischemic stroke, analyses controlling for presenting severity have substantially greater power to delineate relations between process of care variables such as OTT and outcome," they comment.

The strongest predictors of a shorter OTT were higher NIHSS score, arrival by ambulance, arrival during regular hospital hours (Monday-Friday, 07:00-17:00), and a higher annual hospital volume of stroke thrombolysis cases.

"These findings support intensive efforts to accelerate patient presentation and to streamline regional and hospital systems of acute stroke care to compress OTT times," say Saver et al.

medwireNews (www.medwirenews.com) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2013

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