Sheth Kevin N, Solomon Nicole, Alhanti Brooke, Messe Steven R, Xian Ying, Bhatt Deepak L, Hemphill J Claude, Frontera Jennifer A, Chang Raymond C, Danelich Ilya M, Huang Joanna, Schwamm Lee, Smith Eric E, Goldstein Joshua N, Mac Grory Brian, Fonarow Gregg C, Saver Jeffrey L
Yale Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
JAMA Neurol. 2024 Feb 9;81(4):363-72. doi: 10.1001/jamaneurol.2024.0221.
Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice.
To evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the American Heart Association Get With The Guidelines-Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023.
Anticoagulation-associated ICH.
DTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined.
Of 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non-vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity.
In US hospitals participating in Get With The Guidelines-Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.
脑出血（ICH）是最致命的中风亚型，在抗凝相关脑出血中死亡率尤其高。最近，已制定了特定的抗凝逆转策略，但在临床实践中，门到治疗（DTT）时间是否存在时间依赖性治疗效果尚不清楚。
评估在接受逆转干预治疗的抗凝相关脑出血患者中，DTT时间是否与预后相关。
设计、设置和参与者：这项队列研究使用了美国心脏协会“遵循指南-中风”质量改进登记处的数据。纳入了2015年至2021年在美国465家医院症状发作后24小时内就诊的脑出血患者。数据于2023年1月至9月进行分析。
抗凝相关脑出血。
使用逻辑回归模型分析DTT时间和结局，并对人口统计学、病史、基线和医院特征进行调整，采用医院特定的随机截距来考虑地点聚类。感兴趣的主要结局是住院综合死亡率和临终关怀出院。还检查了其他预先指定的次要结局，包括功能结局（出院时改良Rankin量表评分、活动状态和出院地点）。
在9492例有抗凝相关脑出血且记录了逆转干预状态的患者中，4232例（44.6%）为女性，中位（IQR）年龄为77（68-84）岁。共有7469例（78.7%）接受了逆转治疗，其中服用华法林的5429例中有4616例（85.0%），服用非维生素K拮抗剂口服抗凝剂的4069例中有2856例（70.2%）。对于5224例接受逆转干预且记录了工作流程时间的患者，中位（IQR）发病到治疗时间为232（142-482）分钟，中位（IQR）DTT时间为82（58-117）分钟，1449例（27.7%）的DTT时间为60分钟或更短。DTT时间为60分钟或更短与死亡率降低和临终关怀出院相关（调整后的优势比，0.82；95%CI，0.69-0.99），但在功能结局方面无差异（即改良Rankin量表评分为0至3；调整后的优势比，0.91；95%CI，0.67-1.24）。与DTT时间为60分钟或更短相关的因素包括白人种族、较高的收缩压和较低的中风严重程度。
在美国参与“遵循指南-中风”的医院中，早期抗凝逆转与脑出血患者生存率提高相关。这些发现支持为这种毁灭性中风形式的患者加速评估和治疗而做出的密集努力。
