Shorter door-to-needle times improve long-term outcomes in ischemic stroke

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Shorter door-to-needle times improve long-term outcomes in ischemic stroke

Shorter door-to-needle times lowered all-cause mortality and all-cause readmission at 1 year in patients aged at least 65 years with acute ischemic stroke treated with tissue plasminogen activator, researchers found.

Gregg C. Fonarow

“These findings provide evidence that as applied in clinical practice among older adults, acute ischemic patients receiving [tissue plasminogen activator] who had door-to-needle times within 60 minutes had better 1-year clinical outcomes than those with longer treatment times,” Gregg C. Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center, co-director of the UCLA Preventive Cardiology Program, co-chief of the division of cardiology at UCLA and Eliot Corday Chair in Cardiovascular Medicine and Science, told Healio. “Every 15-minute decrease in door-to-needle time was associated with a reduced risk of 1-year all-cause mortality and 1-year all-cause readmission rates.”

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Treatment at Get With the Guidelines-Stroke hospitals

In this retrospective cohort study published in JAMA, Shumei Man, MD, PhD, neurologist at Cleveland Clinic, and colleagues analyzed data from 61,426 patients (median age, 80 years; 44% men) aged at least 65 years with acute ischemic stroke who were treated with IV tissue plasminogen activator from 2006 to 2016. Patients were treated at hospitals that participated in the Get With the Guidelines-Stroke program within 4.5 hours of the time when the patient was known to be well.

Follow-up was conducted for 1 year for the primary outcomes of all-cause readmission, all-cause mortality and a composite of readmission and all-cause mortality.

In this study, the median door-to-needle time was 65 minutes.

Compared with patients treated with tissue plasminogen activator within 45 minutes, those treated with door-to-needle times longer than 45 minutes had higher all-cause readmission (40.8% vs. 38.4%; adjusted HR = 1.08; 95% CI, 1.05-1.12), higher all-cause mortality (35% vs. 30.8%; aHR = 1.13; 95% CI, 1.09-1.18) and higher all-cause mortality or readmission (56% vs. 52.1%; aHR = 1.09; 95% CI, 1.06-1.12).

Patients treated with tissue plasminogen activator with door-to-needle times longer than 60 minutes had higher all-cause readmission (41.3% vs. 39.1%; aHR = 1.07; 95% CI, 1.04-1.1), higher all-cause mortality (35.8% vs. 32.1%; aHR = 1.11; 95% CI, 1.07-1.14) and higher all-cause mortality or readmission (56.8% vs. 53.1%; aHR = 1.08; 95% CI, 1.05-1.1) compared with patients with door-to-needle times within 60 minutes.

Each 15-minute increase in door-to-needle times was significantly linked to higher all-cause mortality within 90 minutes after arriving to the hospital (aHR = 1.04; 95% CI, 1.02-1.05), although this was not observed after 90 minutes (aHR = 1.01; 95% CI, 0.99-1.03). In addition, each 15-minute increased was also associated with higher all-cause readmission (aHR = 1.02; 95% CI, 1.01-1.03) and the composite of all-cause mortality or readmission (aHR = 1.02; 95% CI, 1.01-1.03).

“These data further reinforce that every minute counts in acute ischemic stroke, and that faster treatment translates into better long-term outcomes,” Fonarow said in an interview. “Further, these findings reinforce that national efforts like the AHA’s Target: Stroke [initiative] to improve door-to-needle times can make a meaningful difference in outcomes at the population level.”

Fonarow added that more research is needed in this area. “Additional studies to evaluate longer-term functional status in patients with faster door-to-needle times would help to further expand the evidence base. Studies evaluating the interactions between timely thrombolytic therapy, endovascular interventions and longer-term outcomes would also be of interest,” he said.

Implications for stroke services

In a related editor’s note, Christopher C. Muth, MD, assistant professor in the department of neurological sciences at Rush University Medical Center and senior editor of JAMA, wrote: “This study fills an important gap in the literature by convincingly documenting the association between faster treatment with intravenous [tissue plasminogen activator] and better long-term outcomes including 1-year mortality. The findings are yet another reason for clinicians and health systems to design stroke services that can treat patients with acute ischemic stroke with thrombolytic therapy in a rapid fashion.”

Reference:

• Muth CC. JAMA. 2020;doi:10.1001/jama.2020.5269.

For more information:

Gregg C. Fonarow, MD, can be reached at gfonarow@mednet.ucla.edu; Twitter: @gcfmd.