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16-02-2011 | Stroke | Article

Speed of stroke thrombolysis in US hospitals criticized


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MedWire News: Only about a quarter of stroke patients who are treated with tissue plasminogen activator (tPA) receive the drug within an hour of hospital arrival, show data from the Get With The Guidelines (GWTG-Stroke) initiative.

Greg Fonarow (University of California, Los Angeles, USA) and colleagues stress that the target door-to-needle time of ≤60 minutes "may not be appropriate or achievable in all ischemic stroke patients, particularly those with unstable hemodynamics, respiratory compromise, or challenging clinical presentations."

But they say that their findings "support the need for a collaborative national campaign to improve timely treatment with intravenous tPA."

Indeed, in the current study, despite similar stroke severity at the outset, patients who were thrombolyzed within an hour of arrival were less likely than those with longer door-to-needle times to die in hospital, at 8.6% versus 10.4%, and to suffer symptomatic intracranial hemorrhage, at 4.7% versus 5.6%.

From April 2003 through September 2009, the 1082 hospitals participating in GWTG-Stroke treated 25,504 ischemic stroke patients with intravenous tPA. Just 26.6% of these were treated within 60 minutes of presentation.

Some hospitals treated most of their patients within this time frame, with 79.2% the best rate, but some did not manage to thrombolyze any of their patients within 60 minutes of arrival.

As reported in the journal Circulation, overall rates did increase over time, from 19.5% in 2003 to 29.1% in 2009, which the team describes as a "modest" improvement.

Patients were most likely to receive timely tPA treatment if they were young, male, and arrived during the hospital's regular working hours.

Notably, patients admitted to a Joint Commission primary stroke center were no more likely to receive prompt thrombolysis than those seen in other hospitals. The number of stroke patients admitted to a hospital annually did not affect its speed of thrombolysis treatment, but those that thrombolyzed more than 20 stroke patients annually were twice as likely to manage it within an hour than those that treated less than 10 per year.

Being Black, and having mild neurologic symptoms, atrial fibrillation, or previous stroke counted against patients' chances of receiving timely thrombolysis.

"It is also notable that the symptom-onset-to-arrival times were shorter in patients with door-to-needle times >60 minutes, suggesting that hospitals were taking a more relaxed approach to the administration of tPA in earlier-arriving patients," say the researchers.

MedWire ( is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2011

By Eleanor McDermid