Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke.
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 articleSubject
HumansBrain 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
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https://hdl.handle.net/10161/21835Published Version (Please cite this version)
10.1001/jama.2020.5697Publication 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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Show full item recordScholars@Duke
Roland Albert Matsouaka
Associate Professor of Biostatistics & Bioinformatics
Ying Xian
Adjunct Associate Professor in the Department of Neurology
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