Nearly 30% of ischemic stroke patients with documented symptom start times who were treated at hospitals that participate in a national quality of care improvement initiative presented for treatment within the first 60 minutes of stroke onset, “when the volume of salvageable brain and the patient’s capacity to benefit from reperfusion therapy are the greatest,” Dr. Jeffrey L. Saver and his colleagues reported in the July issue of Stroke, published online ahead of print June 3. Despite their early arrival, however, these patients often have longer waits for clot-busting treatment than do some who arrive later, the authors wrote.

Of 253,148 ischemic stroke patients arriving in the emergency departments of 905 hospitals participating in the American Heart Association/American Stroke Association’s “Get With the Guidelines–Stroke” quality-improvement program between April 2003 and December 2007, 106,924 patients had documented, exact last-known “well” times, and of these 30,220 (28.3%) arrived by ambulance or private vehicle within 60 minutes of those times, the authors wrote. Compared with patients who arrived between 1 and 3 hours after symptom onset, the so-called “golden hour” patients received intravenous thrombolytic therapy significantly more frequently (27.1% vs. 12.9%), however the “door-to-needle” time in the golden hour group was longer, at a mean 90.6 minutes, than was the mean 76.7 minutes observed in the later-arriving patients, they reported. In fact, they stated, only 18.3% of the patients who arrived within the first hour had a door-to-needle time of 60 minutes or less, which is consistent with the national guideline (Stroke 2010 July [doi:10.1161/StrokeAHA.110.583815]).

Although the target door-to-needle times were achieved in fewer than one out of five golden hour patients, “we saw a national trend toward mild improvement over time, particularly at centers with a high treatment volume,” said Dr. Saver of the University of California at Los Angeles. The improvement can likely be attributed to increased public education efforts to recognize stroke symptoms and to emphasize the importance of treatment within the first 30-60 minutes, he said in an interview.

Among the factors associated with an onset-to-door time of 60 minutes or less, the two most powerful determinants of arrival within the first 60 minutes were greater severity of stroke deficits and arrival by ambulance vs. private vehicle,” the authors wrote. “These findings suggest that public health messages have a substantial opportunity to increase the proportion of early-arriving patients by educating patients, family members, and on-scene bystanders to recognize the symptoms of stroke and to react to less severe as well as more severe deficits by calling 9-1-1 [the U.S. emergency phone number] and activating the emergency medical system,” the authors wrote.

The patient and hospital factors associated with decreased odds of arrival within the first hour included older age, female sex, atherosclerotic risk factors, hospital location in the South, and higher annual number of stroke admissions, according to the findings.

The study identifies opportunities nationally for improving door-to-needle time for fibrinolytic therapy and highlights the importance of a door-to-needle time target vs. a “treat-before-final-time window expiration approach,” the authors wrote. “Once patients with ischemic stroke have done their part by arriving at a medial center early, it is incumbent on the receiving hospital to perform rapid diagnostic evaluation and, in appropriate patients, swiftly initiate [intravenous] fibrinolytic therapy,” they stated. “Although there are many valid reasons to delay the start of therapy in early-arriving patients, they are all trumped by the one, overwhelming reason to hurry – the brain is dying all the while that these activities are taking place.”

The Get With the Guidelines–Stroke initiative uses a Web-based patient management tool to collect clinical data on consecutively admitted patients and enable real-time online reporting, according the authors. The current analysis included ischemic stroke data from hospitals that joined the program any time between April 2003 and December 2007, excluding patients who did not present directly to the emergency department.

The findings of the study may be limited by the fact that participating hospitals might have better-organized systems of stroke care than do nonparticipating hospitals, the authors noted. Additionally, they wrote, it is likely that the exact last known well time “is more often documented among early-arriving patients in whom the exact onset time is of less practical importance,” which could skew the results.

The Get With the Guidelines–Stroke initiative is funded by the American Heart Association and the American Stroke Association and is supported by unrestricted educational grants to the American Heart Association by Pfizer Inc. and the Merck–Schering-Plough Partnership. The study authors disclosed serving as consultants to and/or receiving speaking honoraria from multiple companies, including CoAxia Inc., Concentric Medical Inc., Talecris Biotherapeutics, ev3 Inc., Pfizer, Merck and Co., Schering-Plough, Bristol-Myers Squibb, and Sanofi-Aventis.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

Jeffrey L. Saver博士及其同事通过对国家医疗质量改善计划覆盖的医院所收治的缺血性脑卒中患者的症状发作时间记录进行分析后发现，近30%的患者在卒中发作的最初60min内到医院寻求治疗，“在这段时间内，可抢救的脑组织体积最多，患者从再灌注治疗获益的可能性也最高。”不过，研究者指出，尽管及早到达医院，但这些患者等待进行溶栓治疗的时间通常长于到达较晚的患者。该研究6月3日在线发表于《卒中》(Stroke)，其纸质版将于7月份出版。

 

研究者的分析对象为2003年4月~2007年12月期间905家医院急诊科收治的253,148例缺血性脑卒中患者。这些医院均参与了美国心脏协会/美国卒中协会的“依循卒中指南”质量改善计划。在这些患者中，106,924 例患者具有确切的末次已知“健康状况良好”时间的记录，其中30,220例 (28.3%)在症状发作的60min内通过救护车或私家车送达医院。他们指出，与症状发作后1~3h内到达医院的患者相比，所谓的在“黄金时间”内到达医院的患者接受静脉溶栓治疗的比例明显更多(27.1% 对12.9%)，但黄金时间组的从入院至开始溶栓治疗(door-to-needle)的时间长于较晚到达医院的患者(平均90.6min对 76.7min)。他们表示，事实上，在发作后1h内到达医院的患者中，仅18.3%的入院至开始溶栓时间≤60min，与国家卒中指南一致(Stroke 2010 July [doi:10.1161/StrokeAHA.110.583815])。

 

加州大学洛杉矶分校的Saver 博士表示，尽管在入院至开始溶栓时间方面达标的黄金时间组患者的比例低于20%，“但我们在全国范围内观察到医疗质量随时间推移出现轻微改善的趋势，这种趋势在诊治量高的医院特别明显。” 他在接受采访时表示，这种改善可能缘于公共教育工作的加强。这些工作涉及向公众普及对卒中症状的认识及强调在发病后最初30~60min内治疗的重要性。

 

作者指出，在与症状发作至入院(symptom-onset-to-door)时间≤60min相关的因素中，卒中严重程度高与搭乘救护车(相较于私家车)到达医院是两个决定能否在发作后60min内到达医院的最显著因素。作者写道：“这些结果表明，公共卫生教育工作通过向患者及其家属及在场者普及对卒中症状的认识，并教导他们通过拨打911(美国急救电话)和启动急诊医疗系统来应对轻、重发作事件，对于增加及早到达医院的患者比例非常有助益。”

 

结果表明，与在发作后1h内到达医院的几率降低相关的患者因素和医院因素包括老龄、女性性别、动脉粥样硬化危险因素、医院位于南部地区以及每年的高卒中入院率。

 

该研究在全国范围内观察到了入院至开始溶栓治疗时间的改善趋势，并强调了入院至开始溶栓时间目标相较于“在最后时间窗口期结束前施行治疗的措施”的重要性。他们表示，“一旦缺血性脑卒中患者及早到达医院后，接收医院就应义不容辞地迅速进行诊断检查，并对适合的患者迅速进行静脉溶栓治疗。尽管有许多正当理由推迟对及早到达的患者开始进行治疗，但在这些推迟活动进行的时候，脑组织也在死亡，因此迅速抢救才是重中之重。”

 

作者表示，该“依循卒中指南”计划使用基于网络的患者管理系统来收集有关连续入院患者的临床数据，并能够进行实时在线报告。该当前分析所采用的缺血性脑卒中数据来自于在2003年4月~20007年12月期间参与该计划的医院，但排除未直接到急诊科就诊的患者。

 

作者指出，该研究结果的局限性在于，参与医院的卒中治疗系统的组织协调性可能优于非参与医院。此外，他们表示，“对于及早到达医院的患者，可能更常记录到确切末次已知健康状况良好的时间，而确切发作时间对这类患者的实际意义较小”，这可能会使结果产生偏差。

 

 “依循卒中指南”计划获得美国心脏协会和美国卒中协会的资助，并间接获得辉瑞公司和默沙东-先灵葆雅合资企业的支持，因这两家公司为美国心脏协会提供了无限制的教育补助金。该研究作者声明是以下多家公司的顾问，并从这些公司获得演讲酬金：CoAxia 公司、Concentric Medical公司、Talecris Biotherapeutics公司、ev3 公司、辉瑞、默沙东、先灵葆雅、百时美施贵宝和赛诺菲-安万特。