Does Time of Day Or Physician Experience Affect Outcome of Acute Ischemic Stroke Patients Treated with Thrombolysis? a Study from Finland

Abstract

Thrombolytic therapy can be delivered at a steady service level at all times. With proper training, less-experienced physicians can provide high quality thrombolysis, but experience translates into faster treatment.

Stroke Thrombolysis

“…4,5,[20][21][22][23][24] Although typical routine practice in a stroke center has substantial room for improvement, 6 many centers around the world are already down to <30 minutes from arrival to treatment. 5,21 It is important to realize, based on the present analysis, that finetuning even the best of services is beneficial.…”

Within-Day and Weekly Variations of Thrombolysis in Acute Ischemic Stroke

“…41 Finally, other studies, some of which specifically focused on patients treated with thrombolysis, did not observe a night or weekend effect. [25][26][27][28][29] All those studies were conducted in single or few centers in a single country and hence were at risk for center effects, and their results could not be generalized.…”

“…The corresponding author had full access to all the study data, takes responsibility for the integrity of data and accuracy of data analysis, and had final responsibility for the decision to submit for publication. 一些研究报道上午和下午中后段时间脑血管事件发生的风险更 高 [1][2][3][4][5][6] 。有研究认为周末和周一卒中发生率增高 [3,7,8] ，一些研究则认 为周三是卒中发生风险最高的一天，但也有研究认为一周内每天卒中 发生风险没有显著差异 [9][10][11] 。血流动力学和凝血过程的节律变化包括 上午后段时间 [12] 和周末 [13] 血液中纤溶活性降低、血栓形成条件增加， 已用于解释卒中发生的时间差异。 既往研究发现周末和正常工作时间以外时间（下班时间）收治患 者的校正后死亡率更高 [14][15][16] 。非工作时间向病人提供的护理质量的差 异 [8,17,18] 可用于解释周末和下班效应 [14] 。其它研究并未发现周末住 院对卒中患者的住院死亡率有独立影响 [19,20] ，而对于未进行溶栓治 疗的卒中患者而言，日间和夜间发病的总体结局无明显差异 [21] 。 尽管有力的证据证实起病 4.5 小时内进行静脉阿替普酶治疗安 全、有效 [22] ，但仅有少部分缺血性卒中患者能够获得溶栓治疗。因 此，我们急需了解不论是何时何日治疗，溶栓是否可以保证进行，且 具有相同的安全性和有效性。近来关于这方面的研究结果存在争议 [16,[23][24][25][26][27][28][29] ，其中一项研究显示工作时间内接受静脉组织型纤溶酶原激活剂 （tissue-type plasminogen activator, t-PA） 治 疗 的 患 者 死 亡 率更高 [23] ，而另一项研究则报道日间接受 rt-PA 治疗与早期血管再 通及 90 天功能恢复良好有关 [24] 。其它研究发现大部分卒中于非工作 时间接受溶栓及住院不是临床结局的独立预测因素 [16,[25][26][27][28][29] 而就溶栓登记中纳入超过 900 例溶栓患者的国家而言，除英国工作日 治疗比例高于周末外，其它国家在工作日和周末间治疗率无差异，英 国的数据与以往的一项研究结果一致 [33] 。这些数据符合每周卒中发生 的规律，即：周一或周三达到高峰，周末最少 [7.10] 。与我们观察相反的 是，一些研究发现大多数患者接受溶栓治疗是在周末 …”

“…Hence, it is urgent to understand whether the access to thrombolytic treatment is always guaranteed, and with the same safety and efficacy, irrespective of time and day of treatment. Few recent studies on this issue found controversial results, 16,[23][24][25][26][27][28][29] one reporting higher case fatality rates in patients treated during working hours, 23 whereas another reporting that diurnal IV tissue-type plasminogen activator (t-PA) administration was independently associated with early recanalization and better 90-day functional outcome. 24 Other studies showed that the majority of patients with stroke received thrombolysis during nonworking hours and that time of hospital admission was not an independent predictor of outcome.…”

“…24 Other studies showed that the majority of patients with stroke received thrombolysis during nonworking hours and that time of hospital admission was not an independent predictor of outcome. 16,[25][26][27][28][29] In a large cohort of patients treated with IV thrombolysis in several centers from European and non-European countries and entered into the Safe Implementation of Treatments in StrokeInternational Stroke Thrombolysis Register (SITS-ISTR), we aimed to evaluate whether thrombolytic treatment for acute ischemic stroke has a within-day variation corresponding to the circadian pattern of stroke onset and a weekly variability, and whether these have an impact on clinical outcome.…”