Messé Steven R, Khatri Pooja, Reeves Mathew J, Smith Eric E, Saver Jeffrey L, Bhatt Deepak L, Grau-Sepulveda Maria V, Cox Margueritte, Peterson Eric D, Fonarow Gregg C, Schwamm Lee H
From the Department of Neurology (S.R.M.), Hospital of the University of Pennsylvania, Philadelphia; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Epidemiology and Biostatistics (M.J.R.), Michigan State University, East Lansing; Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Neurology and Stroke Center (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School (D.L.B.), Boston, MA; Duke Clinical Research Center (M.V.G.-S., M.C.); Department of Medicine (E.D.P.), Duke University, Durham, NC; and Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA.
Neurology. 2016 Oct 11;87(15):1565-1574. doi: 10.1212/WNL.0000000000003198. Epub 2016 Sep 14.
To determine patient and hospital characteristics associated with not providing IV tissue plasminogen activator (tPA) to eligible patients with acute ischemic stroke (AIS) in clinical practice.
We performed a retrospective cohort study of patients with AIS arriving within 2 hours of onset to hospitals participating in Get With The Guidelines-Stroke without documented contraindications to IV tPA from April 2003 through December 2011, comparing those who received tPA to those who did not. Multivariable generalized estimating equation logistic regression modeling identified factors associated with not receiving tPA.
Of 61,698 eligible patients with AIS presenting within 2 hours of onset (median age 73 years, 51% female, 74% non-Hispanic white, median NIH Stroke Scale score 11, interquartile range 6-18), 15,282 (25%) were not treated with tPA within 3 hours. Failure to give tPA decreased over time from 55% in 2003 to 2005 to 18% in 2010 to 2011 (p < 0.0001). After adjustment for all covariates, including stroke severity, factors associated with failure to treat included older age, female sex, nonwhite race, diabetes mellitus, prior stroke, atrial fibrillation, prosthetic heart valve, NIH Stroke Scale score <5, arrival off-hours and not via emergency medical services, longer onset-to-arrival and door-to-CT times, earlier calendar year, and arrival at rural, nonteaching, non-stroke center hospitals located in the South or Midwest.
Overall, about one-quarter of eligible patients with AIS presenting within 2 hours of stroke onset failed to receive tPA treatment. Thrombolysis has improved dramatically over time and is strongly associated with stroke center certification. Additionally, some groups, including older patients, milder strokes, women, and minorities, may be undertreated.
确定在临床实践中与未向符合条件的急性缺血性卒中（AIS）患者提供静脉注射组织型纤溶酶原激活剂（tPA）相关的患者和医院特征。
我们对2003年4月至2011年12月期间发病2小时内送至参与“遵循卒中指南”项目且无静脉注射tPA记录禁忌症医院的AIS患者进行了一项回顾性队列研究，将接受tPA治疗的患者与未接受治疗的患者进行比较。多变量广义估计方程逻辑回归模型确定了与未接受tPA相关的因素。
在61698例发病2小时内就诊的符合条件的AIS患者中（中位年龄73岁，51%为女性，74%为非西班牙裔白人，中位美国国立卫生研究院卒中量表评分11，四分位间距6 - 18），15282例（25%）在3小时内未接受tPA治疗。未给予tPA的比例随时间从2003年至2005年的55%降至2010年至2011年的18%（p < 0.0001）。在对所有协变量进行调整后，包括卒中严重程度，与未治疗相关的因素包括年龄较大、女性、非白人种族、糖尿病、既往卒中、心房颤动、人工心脏瓣膜、美国国立卫生研究院卒中量表评分<5、非工作时间到达且非通过紧急医疗服务到达、发病至到达时间和门到CT时间较长、较早的日历年以及到达位于南部或中西部的农村、非教学、非卒中中心医院。
总体而言，约四分之一在卒中发病2小时内就诊的符合条件的AIS患者未接受tPA治疗。随着时间推移，溶栓治疗有显著改善，且与卒中中心认证密切相关。此外，一些群体，包括老年患者、症状较轻的卒中患者、女性和少数族裔，可能接受治疗不足。
