Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care
Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care
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DOI：
10.1212/wnl.0000000000200018
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发表时间：
2022-04-05
期刊：
影响因子：
9.9
通讯作者：
Rundek, Tatjana
中科院分区：
文献类型：
--
作者：
Alkhachroum, Ayham;Bustillo, Antonio J.;Rundek, Tatjana
背景和目的急性缺血性卒中（AIS）后早期意识障碍（ECD）的研究尚不充分。ECD可能会影响结局以及暂停或撤销维持生命治疗的决定。方法我们研究了2010年至2019年期间参加佛罗里达卒中登记的122家医院的AIS患者。我们研究了ECD对住院死亡率、暂停或撤销生命维持治疗（WLST）、出院时的监护状态、住院时间和出院处置的影响。结果在238，989例AIS患者中，32，861例（14%）在卒中表现时有ECD。总体而言，平均年龄为72岁（Q1 61，Q3 82），49%为女性，63%为白色，18%为黑人，14%为西班牙裔。与无ECD的患者相比，有ECD的患者年龄较大，（77岁vs 72岁），更常见的是女性（54% vs 48%），有更多的合并症，根据美国国立卫生研究院卒中量表评估的卒中严重程度更高（评分>= 5 49% vs 27%），WLST率更高（21% vs 6%），住院死亡率更高（9% vs 3%）。使用校正模型解释基本特征，ECD患者的住院死亡率较高（比值比[OR] 2.23，95% CI 1.98 - 2.51），住院时间较长（OR 1.37，95% CI 1.33 - 1.44），出院回家或康复的可能性较小（OR 0.54，95% CI 0.52 - 0.57），独立行走的可能性较小（OR 0.61，95% CI 0.57 - 0.64）。WLST显著介导了ECD对死亡率的影响（介导效应265; 95% CI 217 - 314）。在时间趋势分析中，我们发现早期WLST（= 2天）显著降低（R-2 0.7，p = 0.004）。讨论在这项大型前瞻性多中心卒中登记研究中，存在ECD的AIS患者死亡率较高，出院结局较差。死亡率在很大程度上受到WLST决定的影响。
Background and Objectives Early consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment. Methods We studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition. Results Of 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score >= 5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98-2.51), had longer hospitalization (OR 1.37, 95% CI 1.33-1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52-0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57-0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217-314). In temporal trend analysis, we found a significant decrease in early WLST (= 2 days) (R-2 0.7, p = 0.004). Discussion In this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.