Perception of ample time delays stroke thrombolysis
MedWire News: Physicians may be too relaxed when treating patients with stroke who present very early within the treatment window for thrombolysis, research indicates.
Data from nine Eastern European countries show a progressive reduction in door-to-needle times with increasing time from symptom onset to presentation.
"Consequently, although physicians manage to thrombolyze patients arriving at the end of the treatment window, they simultaneously waste the opportunity to offer highly effective treatment to patients arriving early," say Robert Mikulík (St Anne's Hospital, Brno, Czech Republic) and team.
The researchers took their data from the Safe Implementation of Thrombolysis in Stroke (SITS)-East registry, comprising 5563 patients who were treated within 4.5 hours of symptom onset. Overall, 38% of patients had a door-to-needle time of 60 minutes or less, although this varied from 18% to 84% depending on the center.
Each 10-minute increase in the time between symptom onset and hospital arrival was associated with a 19% increase in the likelihood for patients having a door-to-needle time of 60 minutes of less, independent of confounders.
But increasing door-to-needle time was associated with a reduction in the likelihood for patients achieving an excellent functional outcome at 3 months (modified Rankin Scale 0-1), by 14% for each 60-minute rise.
Notably, the proportion of patients with a door-to-needle time of 60 minutes or less fell after the window for intravenous thrombolysis was extended from 3.0 to 4.5 hours. Further analysis showed that this effect was restricted to eight centers (of 124).
"The effect of the treatment window extension on [door-to-needle time] needs to be closely watched and clarified," Mikulík et al write in Stroke.
The proportion of patients treated within 60 minutes of arrival was consistent across most of the range of the National Institutes of Health Stroke Scale score, but decreased markedly among patients with scores of less than 5 of or 27 or higher, ie, those with mild or very severe stroke. This effect remained significant on multivariate analysis, which also showed that the younger patients were, the more likely they were to receive rapid treatment.
The researchers highlight research showing that age and baseline stroke severity do not affect the efficacy of thrombolysis.
"It is necessary to improve adherence to guidelines and to treat patients as soon as possible after arrival to the hospital (in the majority within 60 minutes) regardless of the amount of time left to the end of thrombolytic window and in all patients for whom thrombolysis is indicated," they conclude.
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By Eleanor McDermid