Treatment With Tissue Plasminogen Activator and Inpatient Mortality Rates for Patients With Ischemic Stroke Treated in Community Hospitals

Reed, Shelby D.; Cramer, Steven C.; Blough, David K.; Meyer, Kerry; Jarvik, Jeffrey G.

doi:10.1161/01.str.32.8.1832

Cited by 228 publications

(181 citation statements)

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“…We found no difference in the occurrence of SICH and early in-hospital mortality between the sub-3 h and 3-4.5 h groups. We observed a similar incidence of SICH (5.7%) and early in-hospital mortality (9.7%) in thrombolysis up to 4.5 h as were reported in the NINDS study [1] and other t-PA registries [7,[12][13][14][15][16][17][18][19], where most patients were treated within 3 h. In the ATLANTIS trial [4], 7.0% of the t-PA treated patients in the 3-5 h time window had a SICH, compared to 5.3% in our cohort.…”

Section: Discussionsupporting

confidence: 86%

“…A substantial number of ischemic stroke patients may benefit from intravenous t-PA treatment by extending the time window to 4.5 h. In our cohort, about 1 in 5 of all admitted ischemic stroke patients were treated with t-PA, which is a higher proportion than reported in previous studies [7,13,15,16,18].…”

Section: Discussionmentioning

confidence: 63%

“…Unfortunately, many patients still arrive at the hospital beyond the 3 h time window [5][6][7][8]. Extending the time window would allow more ischemic stroke patients to benefit from intravenous t-PA treatment.…”

Section: Introductionmentioning

confidence: 99%

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Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Uyttenboogaart

Vroomen

Stewart

et al. 2007

Journal of the Neurological Sciences

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Background: The administration of tissue plasminogen activator (t-PA) has been proven effective for ischemic stroke within 3 h after onset. A pooled-analysis of six trials showed that intravenous t-PA still improves outcome when given between 3 to 4.5 h after stroke onset. On the basis of this pooled analysis, t-PA was also routinely offered to our patients between 3-4.5 h. We report the safety and clinical features of this group together with the features of the group given t-PA within 3 h. Methods: Prospectively patient characteristics, stroke severity, stroke subtype, incidence of symptomatic intracerebral hemorrhage (SICH), in-hospital mortality, and 3-months modified Rankin Scale scores (mRS) were registered. Data was analyzed separately for patients treated within 3 h (early group) and those treated between 3-4.5 h (late group). Results: Among 176 patients who underwent intravenous thrombolysis, 101 were treated in the early group and 75 in the late group. Six (5.9%; 95% CI 2.8%-12.3%) patients in the early group and 4 (5.3%; 95% CI 2.2%-12.9%) in the late group developed SICH (p = 1.0). In the early group 13 (12.9%; 95% CI 7.7%-20.8%) patients died within 7 days after admission, compared to 5 (6.7%; 95% CI 3.0%-14.7%) in the late group (p = 0.179). In the early group 44 (43.6%; 95% CI 43.3%-53.3%) were independent (mRS ≤ 2) at three months, compared to 36 (48.0%; 95% CI 37.0%-59.1%) in the late group (p = 0.559). Conclusion: Our data show no trend of decreased safety of thrombolysis beyond 3 h. Due to a small sample size a harmful effect cannot be excluded but seems unlikely.

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 63%

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Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Uyttenboogaart

Vroomen

Stewart

et al. 2007

Journal of the Neurological Sciences

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“…Similar studies looking at delays in New York and in the Stroke Belt did not find an association between ethnicity and delay [75,76], whereas another study conducted in San Diego detected a trend toward delayed presentation among blacks [77]. Also, blacks were less likely to receive intravenous tPA [78,79]. Although delays in presentation and contraindications were seen more frequently in blacks, these were not statistically significant from whites [78].…”

Section: Effect Of Race Ethnicity On Outcomesmentioning

confidence: 95%

Stroke Epidemiology: Advancing Our Understanding of Disease Mechanism and Therapy

2011

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Stroke is the fourth killer and number one cause of adult disability in the United States. The estimated direct and indirect costs of stroke care in this country are $68.9 billion for 2009. The prevalence of stroke and its cost will undoubtedly rise as the aging population increases. In addition, stroke incidence and mortality are increasing in less developed countries in which the lifestyles and population restructuring are rapidly changing. More population-based research to assess incidence, risk factors, and outcomes are needed in these countries. Epidemiologic studies can help identify groups of individuals or regions at higher risk for stroke. They can also help us better understand the natural history of certain conditions and therefore push the direction of therapeutic investigations. Furthermore, the study of trends across different time periods and different populations can help investigators evaluate the effects of stroke care programs and treatment options.

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“…Some previous studies have shown that black patients receive IV rt‐PA 1/5 to 3/4 as often as white patients,8, 9, 21, 22, 23, 24 but other studies have reported no difference in rates of treatment 25, 26. Data for Hispanic patients are also conflicting.…”

mentioning

confidence: 97%

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

Aparicio

Carr

Kasner

et al. 2015

JAHA

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BackgroundPrimary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt‐PA) than non‐PSCs. The impact of PSCs on racial disparities in rt‐PA use is unknown.Methods and ResultsWe used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt‐PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt‐PA at PSCs than non‐PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis‐related group–based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt‐PA than whites at non‐PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt‐PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt‐PA did not reach significance (P=0.98).ConclusionsRacial disparities in intravenous rt‐PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non‐PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt‐PA in the fully adjusted model.

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Treatment With Tissue Plasminogen Activator and Inpatient Mortality Rates for Patients With Ischemic Stroke Treated in Community Hospitals

Cited by 228 publications

References 50 publications

Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Safety of routine IV thrombolysis between 3 and 4.5 h after ischemic stroke

Stroke Epidemiology: Advancing Our Understanding of Disease Mechanism and Therapy

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

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