For patients presenting with acute ischemic stroke, is earlier onset of thrombolytic therapy associated with better outcomes?
Earlier thrombolytic therapy in patients with acute ischemic stroke is associated with improved outcomes, including reduced inpatient mortality, fewer intracranial bleeds, higher rates of independent ambulation at discharge, and increased number of discharges to home. These findings support continued efforts to accelerate the process of acute stroke care delivery and to promote earlier patient presentation after stroke symptom onset. (LOE = 2b)
Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 2013;309(23):2480-2488.
Inpatient (any location)
Previous data from 8 clinical trials of almost 2000 patients suggests that earlier thrombolytic therapy for ischemic stroke is most beneficial. The authors of the current study aimed to confirm the generalizability of these findings in patients treated for stroke in routine clinical practice. Using data from the American Heart Association’s Get with the Guidelines stroke registry, these investigators examined the association between onset to treatment (OTT) time with intravenous tissue-type plasminogen activator (tPA) and outcomes for patients presenting with acute ischemic stroke. Almost 60,000 patients who received tPA within the guideline-recommended maximum of 4.5 hours of symptom onset were included in the analysis. Of this group, the median age was 72 years, 50% were women, and the median OTT time was 144 minutes. OTT times were further subdivided into 0 to 90-minute, 91- to 180-minute, and 181- to 270-minute intervals. Overall, 77% of the patients had an OTT time within 91 to 180 minutes while14% were treated between 181 and 270 minutes and 9% were treated within 90 minutes. Patients with earlier OTT times had higher stroke severity, were more likely to arrive by emergency medical service transport, and were more likely to present during regular weekday hours. Hospitals with higher volumes of tPA cases also had earlier OTT times. Out of the total study population, 33% were walking independently at discharge and almost 40% were discharged to home; 9% died in the hospital prior to discharge and 5% experienced intracranial bleeds. After adjusting for patient factors including stroke severity and hospital factors including volume of tPA-treated patients, the authors noted that earlier OTT times were associated with better outcomes. Among 1000 patients, every 15-minute-faster interval of treatment resulted in 8 more patients walking independently at discharge, 7 more patients being discharged to home, and 4 fewer patients dying in the hospital. Additionally, for every 15-minute decrease in OTT, bleeding events such as symptomatic intracranial bleeds and serious systemic bleeds were less likely to occur.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.