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Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke.

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Date
2020-06
Authors
Man, Shumei
Xian, Ying
Holmes, DaJuanicia N
Matsouaka, Roland A
Saver, Jeffrey L
Smith, Eric E
Bhatt, Deepak L
Schwamm, Lee H
Fonarow, Gregg C
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Abstract
Importance:Earlier administration of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months. However, it remains unclear whether shorter door-to-needle times translate into better long-term outcomes. Objective:To examine whether shorter door-to-needle times with intravenous tPA for acute ischemic stroke are associated with improved long-term outcomes. Design, Setting, and Participants:This retrospective cohort study included Medicare beneficiaries aged 65 years or older who were treated for acute ischemic stroke with intravenous 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. Exposures:Door-to-needle times for intravenous tPA. Main Outcomes and Measures:The primary outcomes were 1-year all-cause mortality, all-cause readmission, and the composite of all-cause mortality or readmission. Results:Among the 61 426 patients treated with tPA within 4.5 hours, the median age was 80 years and 43.5% were male. The median door-to-needle time was 65 minutes (interquartile range, 49-88 minutes). 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; adjusted HR, 1.13 [95% CI, 1.09-1.18]), higher all-cause readmission (40.8% vs 38.4%; adjusted HR, 1.08 [95% CI, 1.05-1.12]), and higher all-cause mortality or readmission (56.0% vs 52.1%; adjusted HR, 1.09 [95% CI, 1.06-1.12]). 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; adjusted hazard ratio [HR], 1.11 [95% CI, 1.07-1.14]), higher all-cause readmission (41.3% vs 39.1%; adjusted HR, 1.07 [95% CI, 1.04-1.10]), and higher all-cause mortality or readmission (56.8% vs 53.1%; adjusted HR, 1.08 [95% CI, 1.05-1.10]). Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause mortality (adjusted HR, 1.04 [95% CI, 1.02-1.05]) within 90 minutes after hospital arrival, but not after 90 minutes (adjusted HR, 1.01 [95% CI, 0.99-1.03]), higher all-cause readmission (adjusted HR, 1.02; 95% CI, 1.01-1.03), and higher all-cause mortality or readmission (adjusted HR, 1.02 [95% CI, 1.01-1.03]). Conclusions and Relevance: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.
Type
Journal article
Subject
Humans
Brain Ischemia
Tissue Plasminogen Activator
Fibrinolytic Agents
Thrombolytic Therapy
Patient Readmission
Infusions, Intravenous
Incidence
Cause of Death
Proportional Hazards Models
Retrospective Studies
Follow-Up Studies
Aged
Aged, 80 and over
Female
Male
Stroke
Time-to-Treatment
Permalink
https://hdl.handle.net/10161/21835
Published Version (Please cite this version)
10.1001/jama.2020.5697
Publication Info
Man, Shumei; Xian, Ying; Holmes, DaJuanicia N; Matsouaka, Roland A; Saver, Jeffrey L; Smith, Eric E; ... Fonarow, Gregg C (2020). Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke. JAMA, 323(21). pp. 2170-2184. 10.1001/jama.2020.5697. Retrieved from https://hdl.handle.net/10161/21835.
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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Scholars@Duke

Matsouaka

Roland Albert Matsouaka

Assistant Professor of Biostatistics & Bioinformatics

Ying Xian

Adjunct Associate Professor in the Department of Neurology
Alphabetical list of authors with Scholars@Duke profiles.
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