Effect of daytime, weekday and year of admission on outcome in acute ischaemic stroke patients treated with thrombolytic therapy

Abstract

Background: Since doubts were raised, if a challenging medical procedure such as acute stroke treatment including thrombolysis with recombinant tissue plasminogen activator (rTPA) is available with identical standard and outcome 24 h and 7 days a week our aim was to examine if acute stroke patients defined by onset-admission time (OAT) of £ 3 h were treated differently or had distinct outcome when admitted during off duty hours (day versus night and weekend versus weekdays) and if any differences in treatment or outcome were apparent when comparing patients admitted in the year 2003 with patients admitted in the year 2006. Methods: We analyzed 2003-2006 data of a prospective registry and grouped patients by time, day, and year of admission. The evaluation was limited to patients that were diagnosed with ischaemic stroke and with OAT of £ 3 h. Medical and sociodemographic items, use of thrombolytic treatment, complications during clinical course and place of discharge were obtained. Clinical state on admission and discharge was assessed using the modified Rankin scale. Comparison with chi-square test, t-test and logistic regression was performed. Results: PatientÕs characteristics, rate of thrombolysis, and outcome were independent from time or day of admission. Proportion of patients with good clinical state at discharge increased significantly from 2003 to 2006 together with a higher rate of rTPA treatment without increase of intracranial hemorrhage. Proportion of patients discharged in good clinical condition after rTPA treatment increased from 34% to 44%. Conclusions: Stroke treatment in potential candidates for thrombolytic therapy revealed no impairment on weekend or at night already in 2003. During 4 years, it was possible to increase rate of rTPA treatment from 8.9% to 21.8% without increment of complications or death, confirming that rTPA is safe and can be implemented with full daily and weekly coverage.

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

“…33 These data would agree with reported weekly variation in stroke onset, the incident of which would peak on Monday or on Wednesday and would be the lowest during the weekend. 7,10 In contrary to our observations, in other studies, the majority of patients with stroke received thrombolysis during the weekend, 16,20,[25][26][27] particularly in comprehensive or primary stroke centers compared with nonstroke centers. 20 Some authors reported stroke onset as being more frequent during the weekend, 3,6,8 and hence, it is not clear whether the differences found in our study have to be related to weekly changes of stroke onset or to differences in stroke service organization.…”

“…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.…”

“…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.…”

High Frequency of Silent Pulmonary Embolism in Patients With Cryptogenic Stroke and Patent Foramen Ovale

“…6 From patients' case files, the following data were added: intake of oral contraceptives, current and previous deep vein thrombosis (DVT), coagulopathy screening (factor V Leiden mutation, antiphospholipid antibodies, protein S and protein C deficiency, antithrombin III deficiency, and prothrombin G20210A mutation), and D-dimer levels assessed within 24 hours after admission.…”