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Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes in Patients With Acute Ischemic Stroke Treated in Clinical Practice.
Abstract
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.
Type
Journal articleSubject
HumansTreatment Outcome
Reperfusion
Registries
Logistic Models
Retrospective Studies
Aged
Middle Aged
United States
Female
Male
Stroke
Endovascular Procedures
Mechanical Thrombolysis
Time-to-Treatment
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https://hdl.handle.net/10161/21624Published Version (Please cite this version)
10.1001/jama.2019.8286Publication Info
Jahan, Reza; Saver, Jeffrey L; Schwamm, Lee H; Fonarow, Gregg C; Liang, Li; Matsouaka,
Roland A; ... Smith, Eric E (2019). Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes
in Patients With Acute Ischemic Stroke Treated in Clinical Practice. JAMA, 322(3). pp. 252-263. 10.1001/jama.2019.8286. Retrieved from https://hdl.handle.net/10161/21624.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Roland Albert Matsouaka
Associate Professor of Biostatistics & Bioinformatics
Eric David Peterson
Fred Cobb, M.D. Distinguished Professor of Medicine
Dr Peterson is the Fred Cobb Distinguished Professor of Medicine in the Division of
Cardiology, a DukeMed Scholar, and the Past Executive Director of the Duke Clinical
Research Institute (DCRI), Durham, NC, USA.
Dr Peterson is the Principal Investigator of the National Institute of Health, Lung
and Blood Institute (NHLBI) Spironolactone Initiation Registry Randomized Interventional
Trial in Heart Failure With Preserved Ejection Fraction (SPIRRIT) Trial He is also
the Principal I
This author no longer has a Scholars@Duke profile, so the information shown here reflects
their Duke status at the time this item was deposited.
Ying Xian
Adjunct Associate Professor in the Department of Neurology
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