Still useless. WHEN THE HELL WILL YOU DETERMINE THE DELIVERY TIME NEEDED FOR 100% RECOVERY WHEN USING tPA? Without that knowledge you are just shooting in the dark. We don't want better recovery, we want 100% recovery. GET THERE! This is all still a complete failure because there is no strategy to solve stroke and never will be until we get survivors in charge.
Shrinking Door-to-Needle Time in Stroke Proves Its Worth
Large study affirms better outcomes with quicker start to thrombolysis(Your tyranny of low expectations is completely visible to all. You all need to be fired.)
One year later, ischemic stroke patients treated with intravenous tissue plasminogen activator (tPA) who had door-to-needle times longer than 45 minutes had higher all-cause mortality (35.0% vs 30.8%) and higher all-cause hospital readmission (40.8% vs 38.4%) than patients with shorter times to treatment, reported Gregg Fonarow, MD, of the University of California Los Angeles, and colleagues.
Within a 90-minute window after hospital arrival, every 15-minute increase in door-to-needle time upped the risk of 1-year all-cause death (HR 1.04) or readmission (HR 1.02), they wrote in JAMA.
"Faster treatment translates into better long-term outcomes in patients with stroke," Fonarow said.
"For every 15 minutes improvement in treatment time, improvements in 1-year outcomes were observed," he told MedPage Today.
Faster tPA treatment is associated with better short-term outcomes, but it's less certain whether faster treatment also has long-term benefit, noted Christopher Muth, MD, of Rush University Medical Center in Chicago and senior editor of JAMA, in an accompanying commentary.
"Clinical trial data have not demonstrated a long-term mortality benefit with thrombolytic therapy, perhaps because trials were underpowered for this outcome," Muth wrote. Observational studies have shown better long-term survival in tPA-treated than untreated patients, but have not matched granular treatment data with long-term outcomes, he added.
In this study, Fonarow and colleagues linked detailed information about time to treatment from hospitals participating in the Get With The Guidelines-Stroke (GWTG-Stroke) registry with long-term clinical outcomes from Medicare claims data.
The researchers evaluated associations between door-to-needle times and 1-year outcomes for 61,426 patients with acute ischemic stroke who were treated with intravenous tPA from 2006 to 2016 within 4.5 hours from the time they were last known to be well.
Median age was 80, 43.5% were men, and 82% were white. Median door-to-needle time was 65 minutes.
The 48,666 patients who had a door-to-needle time longer than 45 minutes had significantly higher 1-year all-cause mortality (HR 1.13, 95% CI 1.09-1.18) and higher all-cause hospital readmission (HR 1.08, 95% CI 1.05-1.12) than patients treated within 45 minutes.
They did not, however, have significantly higher recurrent stroke readmission (HR 1.05, 95% CI 0.98-1.12) at 1 year.
A total of 34,367 patients had door-to-needle times longer than 60 minutes. They, too, had significantly higher all-cause mortality (HR 1.11, 95% CI 1.07-1.14) and all-cause readmission (HR 1.07, 95% CI 1.04-1.10) than patients treated within 60 minutes.
Door-to-needle time within 30 minutes was not associated with even better 1-year outcomes, but the analyses may have been underpowered for this group (5.6% of total patients), the researchers noted.
While the study's large sample size is a plus, the dataset and study design have limitations that may affect its generalizability, Muth pointed out. Only older adults were included, as evidenced by the median age of 80. More than 41,000 people in the GWTG-Stroke registry were excluded because their records couldn't be linked with Medicare claims data, including a higher proportion of racial and ethnic minorities. In addition, patients who received concomitant therapy with intra-arterial reperfusion techniques were not part of the study.
Disclosures
The GWTG-Stroke
program is provided by the American Heart Association/American Stroke
Association and supported by Novartis, Boehringer Ingelheim, Lilly, Novo
Nordisk, Sanofi, AstraZeneca, and Bayer.
Fonarow disclosed support from the Patient-Centered Outcomes Research Institute and the NIH, as well as serving as an associate editor of JAMA Cardiology. Co-authors disclosed multiple relevant relationships with industry. One co-author disclosed serving as an associate editor of JAMA Cardiology.
Muth disclosed no relevant relationships with industry.
Fonarow disclosed support from the Patient-Centered Outcomes Research Institute and the NIH, as well as serving as an associate editor of JAMA Cardiology. Co-authors disclosed multiple relevant relationships with industry. One co-author disclosed serving as an associate editor of JAMA Cardiology.
Muth disclosed no relevant relationships with industry.
Primary Source
JAMA
Secondary Source
JAMA
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