Zha Alicia, Rosero Adriana, Malazarte Rene, Bozorgui Shima, Ankrom Christy, Zhu Liang, Joseph Michele, Trevino Alyssa, Cossey Tiffany D, Savitz Sean, Wu Tzu Ching, Jagolino-Cole Amanda
Institute for Stroke and Cerebrovascular Disease (AZ, AR, LZ, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, Houston, TX; and Department of Neurology (AZ, AR, RM, SB, CA, LZ, MJ, AT, TDC, SS, TCW, AJ-C), The University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, Houston, TX.
Neurol Clin Pract. 2021 Jun;11(3):e287-e293. doi: 10.1212/CPJ.0000000000000975.
Tissue plasminogen activator (tPA) refusal is 4%-6% for acute ischemic stroke (AIS) in the emergency department. Telestroke (TS) has increased the use of tPA for AIS but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.
Patients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.
Among the 1,242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic Black patients and patients with a prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and were associated with a final diagnosis of stroke mimic (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.15-0.36). Good outcome (90-day modified Rankin Scale 0-2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42-1.54). The most common reasons for refusal were rapidly improving and mild/nondisabling symptoms and concern for potential side effects.
tPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared with those who refused. Sex and racial differences associated with an increased tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.
在急诊科，急性缺血性卒中（AIS）患者中组织型纤溶酶原激活剂（tPA）的拒绝率为4%-6%。远程卒中（TS）增加了AIS患者tPA的使用，但伴随着可能影响tPA同意的沟通障碍。我们对我们的TS网络中tPA拒绝的发生率及其相关原因进行了特征描述。
在我们的孤星卒中联盟远程卒中登记处中，确定2015年9月至2018年12月期间根据美国心脏协会指南在症状发作后4.5小时内接受tPA治疗的AIS患者。我们比较了拒绝tPA的患者和接受tPA的患者的基线特征和临床结局。
在1242名符合tPA治疗条件并被提供治疗的患者中，8%拒绝了tPA。女性、非西班牙裔黑人患者以及有卒中病史的患者更有可能拒绝tPA。拒绝tPA的患者美国国立卫生研究院卒中量表（NIHSS）得分较低，且最终诊断为类卒中（优势比[OR]0.23；95%置信区间[CI]0.15-0.36）。接受tPA的患者和拒绝tPA的患者的良好结局（90天改良Rankin量表评分0-2）相同（OR 0.80；95%CI 0.42-1.54）。最常见的拒绝原因是症状迅速改善、症状轻微/无功能障碍以及对潜在副作用的担忧。
通过TS拒绝tPA的情况与先前报道的发生率相当；接受tPA的患者与拒绝tPA的患者的结局没有差异。与tPA拒绝增加相关的性别和种族差异值得进一步研究，以努力在tPA决策中实现公平/平等。
