Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes in Patients With Acute Ischemic Stroke Treated in Clinical Practice

被引:299
作者
Jahan, Reza [1 ]
Saver, Jeffrey L. [2 ]
Schwamm, Lee H. [3 ]
Fonarow, Gregg C. [4 ]
Liang, Li [5 ]
Matsouaka, Roland A. [6 ]
Xian, Ying [5 ]
Holmes, DaJuanicia N. [5 ]
Peterson, Eric D. [5 ]
Yavagal, Dileep [7 ]
Smith, Eric E. [8 ,9 ]
机构
[1] Univ Calif Los Angeles, David Geffen Sch Med, Div Intervent Neuroradiol, Los Angeles, CA 90095 USA
[2] Univ Calif Los Angeles, David Geffen Sch Med, Dept Neurol, Los Angeles, CA USA
[3] Massachusetts Gen Hosp, Dept Neurol, Boston, MA 02114 USA
[4] Univ Calif Los Angeles, David Geffen Sch Med, Div Cardiol, Los Angeles, CA 90095 USA
[5] Duke Clin Res Ctr, Durham, NC USA
[6] Duke Univ, Dept Biostat & Bioinformat, Durham, NC USA
[7] Univ Miami Hlth Syst, Dept Neurol, Miami, FL USA
[8] Univ Calgary, Dept Clin Neurosci, Calgary, AB, Canada
[9] Univ Calgary, Hotchkiss Brain Inst, Calgary, AB, Canada
来源
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION | 2019年 / 322卷 / 03期
关键词
TISSUE-PLASMINOGEN ACTIVATOR; INTRAVENOUS ALTEPLASE; THROMBECTOMY; GUIDELINES; IMPROVEMENT; RECOMMENDATIONS; DISABILITY; PERFUSION; GROWTH; CARE;
D O I
10.1001/jama.2019.8286
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Importance Randomized clinical trials suggest benefit of endovascular-reperfusion therapy for large vessel occlusion in acute ischemic stroke (AIS) is time dependent, but the extent to which it influences outcome and generalizability to routine clinical practice remains uncertain. Objective To characterize the association of speed of treatment with outcome among patients with AIS undergoing endovascular-reperfusion therapy. Design, Setting, and Participants Retrospective cohort study using data prospectively collected from January 2015 to December 2016 in the Get With The Guidelines-Stroke nationwide US quality registry, with final follow-up through April 15, 2017. Participants were 6756 patients with anterior circulation large vessel occlusion AIS treated with endovascular-reperfusion therapy with onset-to-puncture time of 8 hours or less. Exposures Onset (last-known well time) to arterial puncture, and hospital arrival to arterial puncture (door-to-puncture time). Main Outcomes and Measures Substantial reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), ambulatory status, global disability (modified Rankin Scale [mRS]) and destination at discharge, symptomatic intracranial hemorrhage (sICH), and in-hospital mortality/hospice discharge. Results Among 6756 patients, the mean (SD) age was 69.5 (14.8) years, 51.2% (3460/6756) were women, and median pretreatment score on the National Institutes of Health Stroke Scale was 17 (IQR, 12-22). Median onset-to-puncture time was 230 minutes (IQR, 170-305) and median door-to-puncture time was 87 minutes (IQR, 62-116), with substantial reperfusion in 85.9% (5433/6324) of patients. Adverse events were sICH in 6.7% (449/6693) of patients and in-hospital mortality/hospice discharge in 19.6% (1326/6756) of patients. At discharge, 36.9% (2132/5783) ambulated independently and 23.0% (1225/5334) had functional independence (mRS 0-2). In onset-to-puncture adjusted analysis, time-outcome relationships were nonlinear with steeper slopes between 30 to 270 minutes than 271 to 480 minutes. In the 30- to 270-minute time frame, faster onset to puncture in 15-minute increments was associated with higher likelihood of achieving independent ambulation at discharge (absolute increase, 1.14% [95% CI, 0.75%-1.53%]), lower in-hospital mortality/hospice discharge (absolute decrease, -0.77% [95% CI, -1.07% to -0.47%]), and lower risk of sICH (absolute decrease, -0.22% [95% CI, -0.40% to -0.03%]). Faster door-to-puncture times were similarly associated with improved outcomes, including in the 30- to 120-minute window, higher likelihood of achieving discharge to home (absolute increase, 2.13% [95% CI, 0.81%-3.44%]) and lower in-hospital mortality/hospice discharge (absolute decrease, -1.48% [95% CI, -2.60% to -0.36%]) for each 15-minute increment. Conclusions and Relevance Among patients with AIS due to large vessel occlusion treated in routine clinical practice, shorter time to endovascular-reperfusion therapy was significantly associated with better outcomes. These findings support efforts to reduce time to hospital and endovascular treatment in patients with stroke.
引用
收藏
页码:252 / 263
页数:12
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