Early-Arriving Stroke Patients Often Treated Later

ACEP News
July 2010

By Diana Mahoney
Elsevier Global Medical News

Nearly 30% of ischemic stroke patients with documented symptom start times presented for treatment within the first 60 minutes of onset, but despite their early arrival, waited longer for clot-busting treatment than some later arrivers, Dr. Jeffrey L. Saver and his colleagues reported in the July issue of Stroke, published online ahead of print.

Of 253,148 ischemic stroke patients arriving in the emergency departments of 905 hospitals participating in the American Heart Association/American Stroke Association's "Get With the Guidelines-Stroke" quality-improvement program between April 2003 and December 2007, 106,924 patients had documented, exact last-known "well" times, and of these 30,220 (28.3%) arrived by ambulance or private vehicle within 60 minutes of those times, the authors wrote.

Compared with patients who arrived between 1 and 3 hours after symptom onset, the "golden hour" patients received intravenous thrombolytic therapy significantly more frequently (27.1% vs. 12.9%); however, the "door-to-needle" time in the golden hour group was longer, at a mean 90.6 minutes, than was the mean 76.7 minutes observed in the later-arriving patients, they reported.

In fact, only 18.3% of the patients who arrived within the first hour had a door-to-needle time of 60 minutes or less, which is consistent with the national guideline (Stroke 2010 July [doi:10.1161/StrokeAHA.110.583815]).

Although the target door-to-needle times were achieved in fewer than one out of five golden hour patients, "we saw a national trend toward mild improvement over time, particularly at centers with a high treatment volume," said Dr. Saver of the University of California at Los Angeles.

The improvement can likely be attributed to increased public education efforts to recognize stroke symptoms and to emphasize the importance of treatment within the first 30-60 minutes, he said in an interview.

Among the factors associated with an onset-to-door time of 60 minutes or less, the two most powerful determinants of arrival within the first 60 minutes were greater severity of stroke deficits and arrival by ambulance vs. private vehicle, according to the authors.

"These findings suggest that public health messages have a substantial opportunity to increase the proportion of early-arriving patients by educating patients, family members, and on-scene bystanders to recognize the symptoms of stroke and to react to less severe as well as more severe deficits by calling 9-1-1 and activating the emergency medical system," they wrote.

The patient and hospital factors associated with decreased odds of arrival within the first hour included older age, female sex, atherosclerotic risk factors, hospital location in the South, and higher annual number of stroke admissions.

The study identifies opportunities nationally for improving door-to-needle time for fibrinolytic therapy and highlights the importance of a door-to-needle time target vs. a "treat-before-final-time window expiration approach," the authors wrote.

The Get With the Guidelines-Stroke initiative uses a Web-based patient management tool to collect clinical data on consecutively admitted patients and enable real-time online reporting. The current analysis included ischemic stroke data from hospitals that joined the program between April 2003 and December 2007, excluding patients who did not present directly to the emergency department.

The findings of the study may be limited by the fact that participating hospitals might have better-organized systems of stroke care than do nonparticipating hospitals, the authors noted. It also is likely that the exact last known well time "is more often documented among early-arriving patients in whom the exact onset time is of less practical importance," which could skew the results, they wrote.

The Get With the Guidelines-Stroke initiative is funded by the American Heart Association and the American Stroke Association and is supported by unrestricted educational grants from Pfizer Inc. and the Merck-Schering-Plough Partnership.

The study authors disclosed serving as consultants to and/or receiving speaking honoraria from multiple companies, including CoAxia Inc., Concentric Medical Inc., Talecris Biotherapeutics, ev3 Inc., Pfizer, Merck and Co., Schering-Plough, Bristol-Myers Squibb, and Sanofi-Aventis.

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