Popa Daian Ionel, Buleu Florina, Williams Carmen, Tudor Anca, Sutoi Dumitru, Trebuian Cosmin Iosif, Ioan Covasala Constantin, Forțofoiu Dragoș, Badalica-Petrescu Marius, Petre Ion, Iancu Aida, Mederle Ovidiu Alexandru
Doctoral School, Faculty of General Medicine, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
Department of Surgery, Emergency Discipline, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania.
J Pers Med. 2024 Sep 9;14(9):955. doi: 10.3390/jpm14090955.
In the era of personalized medicine, standard protocols regarding the management of acute ischemic stroke (AIS) focus on time targets alone without tailoring the protocol to the specific patient and hospital characteristics to increase IV thrombolysis rates and improve outcomes for these patients by considering organizational differences and patient-related factors that influence adherence to target times at the emergency department level. With this in mind, we evaluate the effect of achieving ED time targets from standard protocol and patient-related risk factors on the intravenous (IV) thrombolysis rate in patients with AIS in the therapeutic window.
For our research, we enrolled people who arrived at the ED with signs of recent AIS with an onset of less than 4.5 h. Initially, 355 patients were included in the study, but through careful screening, only 258 were considered eligible to participate. Of the final group of 258 patients, only 46 received intravenous thrombolysis treatment.
In our study, when we are analyzing ED times in patients admitted with stroke symptoms in the therapeutic window, we found statistically significantly decreased ED times for patients that performed IV thrombolysis compared to patients not performing as follows: a median of 100 min in onset-to-ED door time ( < 0.001), a door-to-physician time (ED doctor) of 4 min ( = 0.009), door-to-blood-samples of 5 min ( = 0.026), a door-to-CT time of 15.5 min ( = 0.009), and door-to-CT results of 37 min ( < 0.001). In addition, patients who received intravenous thrombolysis were found to be significantly older ( < 0.001), with lower height and weight ( < 0.001 for both) and lower Glasgow Coma Scale (GCS) scores (9 ± 4.94 vs. 13.85 ± 2.41, < 0.001). The logistic regression analysis indicated that the onset-to-ED time ( < 0.001) and the door-to-physician time ( = 0.014) for emergency medicine physicians are significant predictors of the likelihood of administering thrombolysis. By analyzing the impact of comorbidities, we observed that dyslipidemia, chronic arterial hypertension, and diabetes mellitus are significant predictive factors for performing IV thrombolysis (the presence of dyslipidemia and diabetes mellitus are predictive factors for performing IV thrombolysis, while the presence of arterial hypertension is not).
The ED time targets that significantly influenced IV thrombolysis in our study were the onset-to-ED door time and the time it takes for the ED doctor to assess the AIS patient (door-to-physician time). The IV thrombolysis rate for these patients was 17.83%, lower than expected despite achieving most ED time targets, with the presence of chronic arterial hypertension as a significant predictive patient-related factor for not performing it. Even though our reported hospital's thrombolysis rate is favorable compared to international reports, there is always room for improvement. Based on our study results, it is necessary that new protocols to customized standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right. Based on our study results, it is necessary that new protocols customize standard protocols and ED time targets for increasing IV thrombolysis rate in patients with AIS in the therapeutic window, focusing more on patient-related factors and type of hospitals, granting personalized medicine its right.
在精准医疗时代，急性缺血性卒中（AIS）管理的标准方案仅侧重于时间目标，而未根据患者和医院的具体特征调整方案，以提高静脉溶栓率并改善这些患者的预后，未考虑在急诊科层面影响达到目标时间的组织差异和患者相关因素。鉴于此，我们评估了在治疗窗内达到标准方案规定的急诊科时间目标及患者相关危险因素对AIS患者静脉（IV）溶栓率的影响。
在本研究中，我们纳入了发病时间小于4.5小时且到急诊科时有近期AIS体征的患者。最初，355例患者纳入研究，但经过仔细筛查，只有258例被认为符合参与条件。在最终的258例患者组中，只有46例接受了静脉溶栓治疗。
在我们的研究中，当分析治疗窗内出现卒中症状的住院患者的急诊科时间时，我们发现与未接受静脉溶栓的患者相比，接受静脉溶栓的患者的急诊科时间在统计学上显著缩短，具体如下：发病至急诊科门口时间中位数为100分钟（<0.001），门口至医生（急诊科医生）时间为4分钟（=0.009），门口至采血时间为5分钟（=0.026），门口至CT时间为15.5分钟（=0.009），门口至CT结果时间为37分钟（<0.001）。此外，发现接受静脉溶栓的患者年龄显著更大（<0.001），身高和体重更低（两者均<0.001），格拉斯哥昏迷量表（GCS）评分更低（9±4.94对13.85±2.41，<0.001）。逻辑回归分析表明，发病至急诊科时间（<0.001）和急诊科医生的门口至医生时间（=0.014）是进行溶栓可能性的显著预测因素。通过分析合并症的影响，我们观察到血脂异常、慢性动脉高血压和糖尿病是进行静脉溶栓的显著预测因素（血脂异常和糖尿病的存在是进行静脉溶栓的预测因素，而动脉高血压的存在则不是）。
在我们的研究中，对静脉溶栓有显著影响的急诊科时间目标是发病至急诊科门口时间以及急诊科医生评估AIS患者所需的时间（门口至医生时间）。这些患者静脉溶栓率为 17.83%，尽管达到了大多数急诊科时间目标，但仍低于预期，慢性动脉高血压的存在是未进行静脉溶栓的显著预测患者相关因素。尽管我们报告的医院溶栓率与国际报告相比是有利的，但仍有改进空间。基于我们的研究结果，有必要制定新的方案，根据患者相关因素和医院类型定制标准方案和急诊科时间目标，以提高治疗窗内AIS患者的静脉溶栓率，赋予精准医疗应有的地位。基于我们的研究结果，有必要制定新的方案，根据患者相关因素和医院类型定制标准方案和急诊科时间目标，以提高治疗窗内AIS患者的静脉溶栓率，赋予精准医疗应有的地位。
