Most Stroke Patients Not Getting tPA Within 1 Hour

February 22, 2011—The American Heart Association/American Stroke Association announced that Gregg C. Fonarow, MD, et al published a study in Circulation concluding that fewer than one-third of patients treated with intravenous tissue-type plasminogen activator (tPA) had door-to-needle times ≤ 60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke, stated Dr. Fonarow, who also presented the study at the International Stroke Conference 2011.

As the investigators noted, the benefits of intravenous tPA in acute ischemic stroke are time dependent, and guidelines recommend an arrival-to-treatment initiation (door-to-needle) time of ≤ 60 minutes. Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1,082 hospitals participating in the Get With the Guidelines stroke program from April 1, 2003, to September 30, 2009, were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤ 60 minutes.

As detailed by the investigators, among 25,504 ischemic stroke patients treated with tPA, door-to-needle time was ≤ 60 minutes in only 6,790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤ 60 minutes were younger age, male gender, white race, or no previous stroke.

Hospital factors associated with ≤ 60-minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. “This suggests that greater hospital team experience translates into improved performance,” commented Dr. Fonarow, who is immediate-past chair of the Get With The Guidelines Steering Committee.

The investigators reported that the proportion of patients with door-to-needle times ≤ 60 minutes varied widely by hospital (0%–79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 (P < .0001). Despite similar stroke severity, in-hospital mortality rates were lower (adjusted odds ratio, 0.78; 95% confidence interval, 0.69–0.9; P < .0003), and symptomatic intracranial hemorrhage was less frequent (4.7% vs 5.6%; P < .0017) for patients with door-to-needle times ≤ 60 minutes compared with patients with door-to-needle times > 60 minutes.

“It is a concern that older patients, women, and black patients were less likely to receive timely tPA administration,” he said. “It's also notable that the symptom onset-to-arrival times were shorter in patients with door-to-needle times of > 60 minutes, suggesting that hospitals were taking a more relaxed approach to the administration of tPA in earlier arriving patients.”

The proportion of patients with door-to-needle times of ≤ 60 minutes varied widely by hospital. Some hospitals did not achieve tPA administration within the ideal time frame for any patient. Other hospitals achieved door-to-needle times of ≤ 60 minutes in 80% or more of patients. The investigators also demonstrated that in-hospital mortality was significantly lower among patients treated more timely with tPA, and there were fewer complications with more timely treatment.

“These findings demonstrate for the first time that shorter door-to-needle times improve the likelihood that acute ischemic stroke patients will survive,” Dr. Fonarow said. The study identifies substantial opportunities nationally for improving the speed of tPA therapy initiation in acute ischemic stroke patients, he said.

“These findings suggest there is a critical need for a targeted campaign tailored to increase the portion of patients with door-to-needle times ≤ 60 minutes, such as the recently launched American Stroke Association Target: Stroke initiative,” added Dr. Fonarow. “Nearly 1,000 hospitals across the country are now registered to use Target: Stroke information and tools to improve their door-to-needle time for administering tPA to appropriate stroke patients.”