Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry
Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry
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DOI：
10.1212/wnl.0000000000003198
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发表时间：
2016-10-11
期刊：
影响因子：
9.9
通讯作者：
Schwamm, Lee H.
中科院分区：
文献类型：
--
作者：
Messe, Steven R.;Khatri, Pooja;Schwamm, Lee H.
目的：确定在临床实践中不向符合条件的急性缺血性卒中（AIS）患者提供静脉注射组织纤溶酶原激活剂（tPA）相关的患者和医院特征。方法：我们对 2003 年 4 月至 2011 年 12 月期间，在发病后 2 小时内到达参加 Get With The Shoulders-Stroke 的医院且无静脉注射 tPA 禁忌证的 AIS 患者进行了一项回顾性队列研究，对接受 tPA 的患者与未接受 tPA 的患者进行了比较。多变量广义估计方程 Logistic 回归模型确定了与不接受 tPA 相关的因素。 结果：在 61,698 名发病 2 小时内出现的符合条件的 AIS 患者中（中位年龄 73 岁，51% 女性，74% 非西班牙裔白人，NIH 中风量表评分中位数 11，四分位数范围 6-18），15,282 名 (25%) 未接受 tPA 治疗3小时内。随着时间的推移，未能给予 tPA 的比例从 2003 年至 2005 年的 55% 下降到 2010 年至 2011 年的 18%（p < 0.0001）。对所有协变量（包括中风严重程度）进行调整后，与治疗失败相关的因素包括年龄较大、女性、非白人种族、糖尿病、既往中风、心房颤动、人工心脏瓣膜、NIH 中风量表评分 5、非工作时间到达且不通过紧急医疗服务、从发病到到达和上门 CT 时间较长、日历年较早以及到达位于南部或南部的农村、非教学、非中风中心医院。中西部结论：总体而言，大约四分之一的符合条件的 AIS 患者在中风发作 2 小时内未能接受 tPA 治疗。随着时间的推移，溶栓治疗得到显着改善，并且与中风中心认证密切相关。此外，某些群体，包括老年患者、轻度中风、女性和少数民族，可能得不到充分治疗。
Objective: To determine patient and hospital characteristics associated with not providing IV tissue plasminogen activator (tPA) to eligible patients with acute ischemic stroke (AIS) in clinical practice.Methods: We performed a retrospective cohort study of patients with AIS arriving within 2 hours of onset to hospitals participating in Get With The Guidelines-Stroke without documented contraindications to IV tPA from April 2003 through December 2011, comparing those who received tPA to those who did not. Multivariable generalized estimating equation logistic regression modeling identified factors associated with not receiving tPA.Results: Of 61,698 eligible patients with AIS presenting within 2 hours of onset (median age 73 years, 51% female, 74% non-Hispanic white, median NIH Stroke Scale score 11, interquartile range 6-18), 15,282 (25%) were not treated with tPA within 3 hours. Failure to give tPA decreased over time from 55% in 2003 to 2005 to 18% in 2010 to 2011 (p < 0.0001). After adjustment for all covariates, including stroke severity, factors associated with failure to treat included older age, female sex, nonwhite race, diabetes mellitus, prior stroke, atrial fibrillation, prosthetic heart valve, NIH Stroke Scale score,5, arrival off-hours and not via emergency medical services, longer onset-to-arrival and door-to-CT times, earlier calendar year, and arrival at rural, nonteaching, non-stroke center hospitals located in the South or Midwest.Conclusions: Overall, about one-quarter of eligible patients with AIS presenting within 2 hours of stroke onset failed to receive tPA treatment. Thrombolysis has improved dramatically over time and is strongly associated with stroke center certification. Additionally, some groups, including older patients, milder strokes, women, and minorities, may be undertreated.