USA: Shorter door-to-needle times in stroke patients (aged 65 years or older) treated with tissue plasminogen activator (tPA), lowers mortality, and hospital readmission at 1 year, according to a recent study. The findings, published in the journal JAMA, support evidence that shortening time to thrombolytic therapy is associated with improved outcomes.
Previous studies have shown earlier administration of intravenous tissue plasminogen activator in acute ischemic stroke to be associated with reduced mortality by the time of discharge from hospital. However, there is a lack of clarity on whether shorter door-to-needle times leads to a better long-term outcome.
Shumei Man, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, and colleagues examined whether the shorter door to needle times with intravenous tPA for acute ischemic stroke is associated with improved long-term outcomes.
The study included Medicare beneficiaries aged 65 years or older (n=61,426) with acute ischemic stroke and were treated with IV tPA within 4.5 hours from the time they were last known to be well at Get With The Guidelines–Stroke participating hospitals between January 1, 2006, and December 31, 2016, with 1-year follow-up through December 31, 2017.
In this study, the median door-to-needle time was 65 minutes.
The primary outcomes were 1-year all-cause mortality, all-cause readmission, and the composite of all-cause mortality or readmission.
Key findings of the study include:
The 48 666 patients (79.2%) who were treated with tPA and had door-to-needle times of longer than 45 minutes, compared with those treated within 45 minutes, had significantly higher all-cause mortality (35.0% vs 30.8%, respectively), higher all-cause readmission (40.8% vs 38.4%), and higher all-cause mortality or readmission (56.0% vs 52.1%).
The 34 367 patients (55.9%) who were treated with tPA and had door-to-needle times of longer than 60 minutes, compared with those treated within 60 minutes, had significantly higher all-cause mortality (35.8% vs 32.1%, respectively), higher all-cause readmission (41.3% vs 39.1%), and higher all-cause mortality or readmission (56.8% vs 53.1%).
Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause mortality within 90 minutes after hospital arrival, but not after 90 minutes, higher all-cause readmission, and higher all-cause mortality or readmission.
"Among patients aged 65 years or older with acute ischemic stroke who were treated with tissue plasminogen activator, shorter door-to-needle times were associated with lower all-cause mortality and lower all-cause readmission at 1 year. These findings support efforts to shorten time to thrombolytic therapy," concluded the authors.
The study, "Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke," is published in the journal JAMA.
DOI: 10.1001/jama.2020.5697