Treating stroke more quickly lowers risk of in-hospital death, hastens discharge

Taken from JAMA – by Bruce Sylvester – After analyzing data on nearly 60,000 patients with acute ischemic stroke, researchers report that thrombolytic treatment initiated sooner correlates to a reduced incidence of in-hospital mortality and intracranial hemorrhage, and to higher rates of independent walking ability at discharge and discharge to home. The study appeared in the June 19, 2013 issue of JAMA.

As background, the authors noted, “Intravenous (IV) tissue-type plasminogen activator (tPA) is a treatment of proven benefit for select patients with acute ischemic stroke as long as 4.5 hours after onset. Available evidence suggests a strong influence of time to therapy on the magnitude of treatment benefit…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.”

Jeffrey L. Saver, M.D., of the David Geffen School of Medicine at UCLA in Los Angeles, and colleagues conducted a retrospective study of data from 58,353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset in 1,395 hospitals, and from April 2003 to March 2012. Median age was 72.

Median OTT time was 144 minutes. The investigators reported that 9.3 percent of subjects had OTT time of 0 to 90 minutes, 77.2 percent had OTT time of 91 to 180 minutes, and 13.6 percent had OTT time of 181 to 270 minutes.

Factors strongly associated with shorter OTT included stroke severity, transport by ambulance and arrival during regular hours.

The investigators reported 5,142 (8.8 percent) of the subjects died in-hospital, 2,873 (4.9 percent) had intracranial hemorrhage, 19,491 (33.4 percent) achieved independent ambulation at hospital discharge, and 22,541 (38.6 percent) were discharged to home.

They found that, for subjects treated in the first 90 minutes after onset, compared with 181-270 minutes after onset, mortality was reduced by 26 percent, symptomatic intracranial hemorrhage was reduced by 28 percent, independence in ambulation at discharge was increased by 51 percent, and discharge to home was increased by 33 percent.

“These findings support intensive efforts to accelerate patient presentation and to streamline regional and hospital systems of acute stroke care to compress OTT times,” the authors concluded.