Off-Hour Admission and Outcomes in Patients with Acute Intracerebral Hemorrhage in the INTERACT2 Trial

Abstract

Background: Conflicting data exist of an association between off-hour (weekend, holiday, or night-time) hospital admission and adverse outcome in intracerebral hemorrhage (ICH). We determined the association between off-hour admissions and poor clinical outcome, and of any differential effect of early intensive blood pressure (BP) lowering treatment between off- and on-hour admissions, among participants of the Intensive BP Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2). Methods: Subsidiary analysis of INTERACT2, a multinational, multicenter, clinical trial of patients with spontaneous ICH with elevated systolic BP, randomly assigned to intensive (target systolic BP <140 mm Hg) or guideline-based (<180 mm Hg) BP management. Primary outcome was death or major disability (modified Rankin scale of 3-6) at 90 days. Off-hour admission was defined as night-time (4:30 p.m. to 8:30 a.m.) on weekdays, weekends (Saturday and Sunday), and public holidays in each participating country. Results: Of 2,794 patients with information on the primary outcome, 1,770 (63%) were admitted to study centers during off-hours. Off-hour admission was not associated with risk of poor outcome at 90 days (53% off-hour vs. 55% on-hour; p = 0.49), even after adjustment for comorbid risk factors (odds ratio 0.92; 95% CI 0.76-1.12). Consistency exists in the effects of intensive BP lowering between off- and on-hour admission (p = 0.85 for homogeneity). Conclusions: Off-hour admission was not associated with increased risks of death or major disability among trial protocol participants with acute ICH. Intensive BP lowering can provide similar treatment effect irrespective of admission hours.

Neutrophil-to-Lymphocyte Ratio Is an Independent Predictor for In-Hospital Mortality in Spontaneous Intracerebral Hemorrhage

“…Bold values are significant, italic values show a statistical trend (i.e., p < 0.1). flammation was significantly associated with unfavorable outcome [16,33,34] ; however, we did not identify NLR as an independent predictor for outcome in ICH [6,16] , which is in line with data from INTERACT2 [18,35] . Regarding functional outcome and its possible relation to hematoma enlargement, Morotti et al [19] -contrary to this study -found associations of higher neutrophil counts with reduced risk of hematoma expansion.…”

Blood Pressure and Anticoagulation Reversal Management during Off-Hours in Oral Anticoagulation-Associated Intracerebral Hemorrhage

“…Yet, as demonstrated here, BP and OAC reversal treatment appear sufficiently established resulting in similar rates of hematoma enlargement, and related clinical outcomes, in on vs. off-hour-admitted OAC-ICH patients. These data are in line with findings from primary spontaneous ICH patients of the INTERACT2 trial (OAC-ICH < 4%) verifying that off-hour admission was not associated with an increased risk for major disability or mortality [16,25]. With regard to the specific BP and anticoagulation reversal management, all patients showed a significant reduction in systolic BP levels from admission to 4 h which remained stable thereafter, indicating established treatment standards at participating institutions that sufficiently work in off-hours.…”

“…On-hour admission was defined as hospital admission within regular working hours (8: 30 a.m. to 4: 30 p.m.) on weekdays. Off-hour hospital admission was defined as admission outside regular working hours on weekdays, weekends (Saturday and Sunday), and public holidays [16].…”

“…1 . Off-hours VKA-ICH patients showed a significant higher National Institutes of Health Stroke Scale (NIHSS), (13 [6-21] vs. 10 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]; p < 0.01), a reduced Glasgow Coma Scale-Score (13 [10][11][12][13][14][15] vs. 14 [11][12][13][14][15]; p = 0.01), and a higher rate of intraventricular hemorrhage (447 [44.5%] vs. 108 [38.7%], p < 0.05) compared to on-hour VKA patients (Table 1). There was no difference regarding the time from symptom onset to hospital admission between on-and offhour VKA patients (98 min [60-266 min] vs. 101 min [60-260 min]; p = 0.97).…”

Editorial

“…In addition, in the last few years, concomitant diseases for stroke have become a major theme of discussion, for example, stroke and cancer [16] or stroke and kidney diseases [17,18]. Stroke researchers and clinicians have to deal with local health networks [19,20], in- and pre-hospital patient triages [21,22] and stroke patients have to be identified while they are being treated for other diseases [23]. Acute stroke treatment now predominantly includes the time in an intensive care unit and we published some interesting manuscripts about this aspect [24,25,26,27].…”