Shorter Door-to-Needle Times Are Associated With Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke.
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2023-07
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Abstract
Background
Existing data and clinical trials could not determine whether faster intravenous thrombolytic therapy (IVT) translates into better long-term functional outcomes after acute ischemic stroke among those treated with endovascular thrombectomy (EVT). Patient-level national data can provide the required large population to study the associations between earlier IVT, versus later, with longitudinal functional outcomes and mortality in patients receiving IVT+EVT combined treatment.Methods
This cohort study included older US patients (age ≥65 years) who received IVT within 4.5 hours or EVT within 7 hours after acute ischemic stroke using the linked 2015 to 2018 Get With The Guidelines-Stroke and Medicare database (38 913 treated with IVT only and 3946 with IVT+EVT). Primary outcome was home time, a patient-prioritized functional outcome. Secondary outcomes included all-cause mortality in 1 year. Multivariate logistic regression and Cox proportional hazards models were used to evaluate the associations between door-to-needle (DTN) times and outcomes.Results
Among patients treated with IVT+EVT, after adjusting for patient and hospital factors, including onset-to-EVT times, each 15-minute increase in DTN times for IVT was associated with significantly higher odds of zero home time in a year (never discharged to home) (adjusted odds ratio, 1.12 [95% CI, 1.06-1.19]), less home time among those discharged to home (adjusted odds ratio, 0.93 per 1% of 365 days [95% CI, 0.89-0.98]), and higher all-cause mortality (adjusted hazard ratio, 1.07 [95% CI, 1.02-1.11]). These associations were also statistically significant among patients treated with IVT but at a modest degree (adjusted odds ratio, 1.04 for zero home time, 0.96 per 1% home time for those discharged to home, and adjusted hazard ratio 1.03 for mortality). In the secondary analysis where the IVT+EVT group was compared with 3704 patients treated with EVT only, shorter DTN times (≤60, 45, and 30 minutes) achieved incrementally more home time in a year, and more modified Rankin Scale 0 to 2 at discharge (22.3%, 23.4%, and 25.0%, respectively) versus EVT only (16.4%, P<0.001 for each). The benefit dissipated with DTN>60 minutes.Conclusions
Among older patients with stroke treated with either IVT only or IVT+EVT, shorter DTN times are associated with better long-term functional outcomes and lower mortality. These findings support further efforts to accelerate thrombolytic administration in all eligible patients, including EVT candidates.Type
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Man, Shumei, Nicole Solomon, Brian Mac Grory, Brooke Alhanti, Ken Uchino, Jeffrey L Saver, Eric E Smith, Ying Xian, et al. (2023). Shorter Door-to-Needle Times Are Associated With Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke. Circulation, 148(1). pp. 20–34. 10.1161/circulationaha.123.064053 Retrieved from https://hdl.handle.net/10161/31117.
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Scholars@Duke
Nicole Solomon
Brian C. Mac Grory
Dr. Brian Mac Grory, MB BCh BAO, MHSc, MRCP, FAHA, FANA is an Associate Professor of Neurology & Ophthalmology at the Duke University School of Medicine and a Staff Neurologist at Duke University Medical Center. He received his medical degree from University College Dublin in Dublin, Ireland in 2011. After an internship at St. Vincent's University Hospital, Dublin, he completed a neurology residency and vascular neurology fellowship at the Yale School of Medicine/Yale-New Haven Hospital in New Haven, Connecticut. Upon completion of his training, he served for 3 years on the faculty of Brown University/Rhode Island Hospital before being recruited to Duke University in 2020.
His clinical practice encompasses both vascular and general neurology in the emergency, inpatient, outpatient, and telemedicine settings. He has a particular clinical interest in central retinal artery occlusion (CRAO or "eye stroke") and has developed a center of excellence for the treatment of this condition at Duke. He led the development of the first ever American Heart Association (AHA) scientific consensus statement on the management of CRAO which was endorsed by six professional medical societies in the United States representing neurology, neurosurgery, cardiology, ophthalmology, neuro-ophthalmology, and optometry.
Dr. Mac Grory has published over 100 peer-reviewed scientific articles appearing in JAMA, British Medical Journal, Circulation, Stroke, Annals of Neurology, JAMA Neurology, and Neurology. His research on retinal vascular disease is funded by the National Institutes of Health/National Heart, Lung, and Blood Institute (K23 HL161426), the AHA (23MRFSCD1077188), and the Duke Office of Physician-Scientist Development (FRCS #2835124). Additionally, he serves as Clinical Lead for the Get With The Guidelines-Stroke Data Analytic Program at the Duke Clinical Research Institute (DCRI) and Associate Program Director for the vascular neurology fellowship program at Duke. His research has been recognized with the Stroke Progress and Innovation Award, Stroke Care in Emergency Medicine Award, and Early Career Investigator Award from the AHA/American Stroke Association. He is a member of the AHA's Stroke Systems of Care Advisory Group, the Stroke Emergency Neurovascular Care Committee, and the Royal College of Physicians of the United Kingdom (MRCP(UK)).
Brooke Alhanti
Ying Xian
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