SAN DIEGO — Patients with ischemic stroke who arrive within 1 hour of symptom onset at a hospital participating in the Get With the Guidelines-Stroke program were significantly more likely to receive thrombolytic therapy, according to a study presented at the International Stroke Conference.
Only 28% of the 106,924 patients studied arrived within that “golden hour,” said lead investigator and vascular neurologist Jeffrey L. Saver of the University of California, Los Angeles. Of those, 27% eventually received intravenous tissue plasminogen activator (tPA), compared with 13% of the patients who arrived 1–3 hours after symptom onset.
Data from prior studies suggested that 25%–30% of golden-hour patients would be eligible for tPA treatment. “We're actually doing pretty well at these hospitals,” Dr. Saver said at a news briefing at the conference sponsored by the American Heart Association, which also sponsored the study.
Rapid treatment requires a “cultural revolution,” according to Dr. Saver. “We are changing our training techniques for the new generation of physicians who are going to be interventionally minded stroke physicians. Every stroke is a treatable emergency, and it is the stroke team member's responsibility to get treatment done as soon as possible. We tell our residents, 'Push the gurney yourself to the CT scanner. Don't wait for the critical care transport nurse. Run the bloods yourself over to the lab. Run and get the tPA [from the pharmacy].'”
The study was retrospective and used data collected between 2003 and 2007 from 905 hospitals. All participating hospitals were part of the Get With the Guidelines-Stroke (GWTG-S) program, and hospital staffs were thus among the most educated on the need for the rapid treatment of people with stroke.
In the golden-hour patients, the average time to thrombolytic treatment—the “door-to-needle” (DTN) time—was 91 minutes. The average DTN for later arriving patients was significantly shorter at 77 minutes, but still longer than the recommended 60-minute target DTN time.
“We do have some room for improvement,” Dr. Saver said. “It's a natural tendency when a patient gets to the hospital early for physicians to take time to make a more considered and deliberate decision. Unfortunately, deliberation comes at the expense of brain when you treat stroke. … Time is brain. Every minute that your patient is not treated, 2 million nerve cells die. We know that every 10 minutes in which [tPA] delivery is delayed, one less patient benefits from treatment.”
In Dr. Saver's view, two factors account for the smaller proportion of late-arriving patients who receive tPA. First, some of them arrive too late for the hospital to complete all the tests before 3 hours have elapsed from the onset of symptoms. tPA is approved only for patients who can be treated within that time limit.
Second, late-arriving patients are more likely to have neurologic deficits that are predicted to be moderate rather than severe. Therefore, a fewer late-arriving patients would be expected to benefit from thrombolytic therapy. It's difficult to tease out the relative contributions of those two factors, Dr. Saver said.
Dr. Saver disclosed relationships with Concentric Medical, CoAxia, Talecris Biotherapeutics, E.E. Smith, Mitsubishi, and Boehringer Ingelheim.