Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke
Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke
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DOI：
10.1001/jama.2013.6959
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发表时间：
2013-06-19
影响因子：
120.7
通讯作者：
Schwamm, Lee H.
中科院分区：
文献类型：
--
作者：
Saver, Jeffrey L.;Fonarow, Gregg C.;Schwamm, Lee H.
重要性随机临床试验表明，静脉注射组织型纤溶酶原激活剂（tPA）治疗急性缺血性卒中的获益具有时间依赖性。然而，适度的样本量限制了对发作至治疗（OTT）时间影响结局的程度的表征;并且该发现对临床实践的普遍性是不确定的。目的评价在用静脉tPA治疗的急性缺血性卒中患者中OTT时间与结果的相关程度。设计，设置，分析了1395家参与指南-卒中项目的医院中58353例症状发作4.5小时内接受tPA治疗的急性缺血性卒中患者的数据，结果58353例tPA治疗患者中位年龄为72岁，50.3%为女性，平均年龄为25岁，50.3%为男性，平均年龄为25岁，50.3%为女性，平均年龄为25岁，50.3%为男性，平均年龄为25岁，50.3%为女性。中位OTT时间为144分钟（四分位距，115-170），9.3%（5404）的OTT时间为0 - 90分钟，77.2%（45029）的OTT时间为91 - 180分钟，13.6%（7920）的OTT时间为181 - 270分钟。87.7%的患者记录的治疗前美国国立卫生研究院卒中量表中位评分为11分（四分位距，6-17分）。与OTT缩短最密切相关的患者因素包括卒中严重程度较高（比值比[ OR]，2.8; 95% CI，每增加5分2.5-3.1）、救护车到达（OR，5.9; 95% CI，4.5-7.3）和在正常时间到达（OR，4.6; 95% CI，3.8-5.4）。总体而言，有5142例（8.8%）住院死亡，2873例（4.9%）患者发生颅内出血，19491例（33.4%）患者在出院时实现独立自主，22541例（38.6%）患者出院回家。更快的OTT，以15分钟为增量，与院内死亡率降低相关（OR，0.96; 95% CI，0.95-0.98; P <0.001），症状性颅内出血减少（OR，0.96; 95% CI，0.95-0.98; P <0.001），出院时独立自主的实现增加（OR，1.04; 95% CI，1.03-1.05; P < .001），出院回家的时间增加（OR，1.03; 95% CI，1.02-1.04; P < .001）。结论和相关性在代表美国临床实践的注册中，早期溶栓治疗与死亡率和症状性颅内出血的降低以及急性缺血性中风后出院时和出院回家时独立行走的比例较高相关。这些发现支持了为加速卒中患者的住院和溶栓治疗所做的大量努力。
Importance Randomized clinical trials suggest the benefit of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke is time dependent. However, modest sample sizes have limited characterization of the extent to which onset to treatment (OTT) time influences outcome; and the generalizability of findings to clinical practice is uncertain.Objective To evaluate the degree to which OTT time is associated with outcome among patients with acute ischemic stroke treated with intraveneous tPA.Design, Setting, and Patients Data were analyzed from 58 353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset in 1395 hospitals participating in the Get With The Guidelines-Stroke Program, April 2003 to March 2012.Main Outcomes and Measures Relationship between OTT time and in-hospital mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination.Results Among the 58 353 tPA-treated patients, median age was 72 years, 50.3% were women, median OTT time was 144 minutes (interquartile range, 115-170), 9.3% (5404) had OTT time of 0 to 90 minutes, 77.2% (45 029) had OTT time of 91 to 180 minutes, and 13.6% (7920) had OTT time of 181 to 270 minutes. Median pretreatment National Institutes of Health Stroke Scale documented in 87.7% of patients was 11 (interquartile range, 6-17). Patient factors most strongly associated with shorter OTT included greater stroke severity (odds ratio [ OR], 2.8; 95% CI, 2.5-3.1 per 5-point increase), arrival by ambulance (OR, 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR, 4.6; 95% CI, 3.8-5.4). Overall, there were 5142 (8.8%) in-hospital deaths, 2873 (4.9%) patients had intracranial hemorrhage, 19 491 (33.4%) patients achieved independent ambulation at hospital discharge, and 22 541 (38.6%) patients were discharged to home. Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR, 0.96; 95% CI, 0.95-0.98; P < .001), reduced symptomatic intracranial hemorrhage (OR, 0.96; 95% CI, 0.95-0.98; P < .001), increased achievement of independent ambulation at discharge (OR, 1.04; 95% CI, 1.03-1.05; P < .001), and increased discharge to home (OR, 1.03; 95% CI, 1.02-1.04; P < .001).Conclusions and Relevance In a registry representing US clinical practice, earlier thrombolytic treatment was associated with reduced mortality and symptomatic intracranial hemorrhage, and higher rates of independent ambulation at discharge and discharge to home following acute ischemic stroke. These findings support intensive efforts to accelerate hospital presentation and thrombolytic treatment in patients with stroke.