Factors linked to stroke undertreatment identified
medwireNews: An analysis of the US Get With The Guidelines–Stroke registry has revealed multiple patient and hospital characteristics associated with failure to provide intravenous tissue plasminogen activator (tPA) therapy in eligible patients with acute ischaemic stroke.
Many of these factors “may be modifiable” and could lead to improved treatment rates in the future, say Steven Messé (Hospital of the University of Pennsylvania, Philadelphia, USA) and team.
The analysis included 61,698 ischaemic stroke patients presenting within 2 hours of onset who did not have any documented thrombolysis contraindications or warnings, a quarter of whom did not receive intravenous tPA.
After adjusting for confounding factors, including stroke severity as assessed by the National Institutes of Health Stroke Scale (NIHSS), women were a significant 8% more likely to not be given tPA than men, as were older patients, with a significant 13% increased likelihood with every 5-year increase in age.
Compared with White ethnicity, being of African–American or other ethnicity was associated with a significant 26% and 17% increased probability of not receiving tPA therapy, respectively.
Patients with mild stroke, defined as an NIHSS score below 5, were also significantly less likely to receive tPA than their counterparts with higher NIHSS scores.
Other patient characteristics that independently predicted nonuse of tPA included a history of atrial fibrillation, peripheral vascular disease, diabetes, stroke or transient ischaemic attack and presence of a prosthetic heart valve.
“These represent opportunities for more targeted education to patients with these risk factors on the need for rapid medical attention and available treatment when stroke symptoms occur”, the researchers write in Neurology.
They also identified several hospital factors linked to lack of tPA use. Specifically, rural, non-teaching hospitals and non-primary stroke centres were less likely to give tPA to eligible patients, as were hospitals located in the South or Midwest and those that failed to routinely document the NIHSS score.
Other parameters related to the speed of evaluation; for instance, arrival during non-work hours and not via emergency medical services reduced the odds of tPA treatment. The time from stroke onset to arrival was also crucial, with a significant 21% increase in the likelihood of not receiving tPA for every 10-minute delay.
Therefore, Messé et al believe that “patient, family, and medical caregiver education about acute stroke symptoms, the importance of the use of [emergency medical services] in this setting, and interventions that expedite the evaluation of potentially eligible stroke patients would likely increase treatment rates.”
Reassuringly, the rates of tPA therapy increased over time, with 82% of eligible patients receiving tPA between 2010 and 2011, compared with less than half (45%) during the 2003–2005 time period.
medwireNews is an independent medical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2015