Results of stroke registry
Why Are Eligible Thrombolysis Candidates Left Untreated?

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Background

Despite proven efficacy, thrombolytics are used in a minority of eligible candidates. Because some of the exclusion criteria are vague, relying on documented contraindications could disguise biases in usage. This study sought to identify barriers to tissue-type plasminogen activator (tPA) treatment among eligible patients with acute ischemic stroke.

Methods

The study prospectively identified all patients with an initial diagnosis of ischemic stroke arriving within 2.5 hours of symptom onset at 11 hospitals participating in the Centers for Disease Control and Prevention–sponsored California Acute Stroke Prototype Registry during two 3-month periods in 2002 and 2003. Potential risk factors for nontreatment with thrombolytics among patients categorized as eligible were examined, based on directly documented contraindications. Analyses were repeated after reclassification of eligibility based on record review.

Results

Of 625 patients with ischemic stroke, 126 (20%) arrived at the emergency department within 2.5 hours of symptom onset. Based on direct documentation, 72 (11.5% of all patients; 57% of in-time arrivals) were eligible for thrombolysis; 32 (44% of eligible patients) who received tPA within the 3-hour time window and 40 who did not receive thrombolytic medications despite having no documented contraindication to treatment. Factors predictive of nontreatment were older age (p=0.0005), later arrival (p=0.004), and admittance to a non-academic hospital (p=0.03). After record review, slightly fewer patients (n=61) were deemed eligible, with a tPA treatment rate of 52% among those eligible. Older age (p=0.002) and later arrival (p=0.002) continued to be predictive of nontreatment with thrombolytics after reclassification.

Conclusions

Even when more-comprehensive eligibility standards are applied, older age and later hospital arrival are associated with nontreatment with thrombolytics.

Section snippets

Data Collection

Data for this study were collected as part of the California Acute Stroke Prototype Registry (CASPR) sponsored by the Centers for Disease Control and Prevention (CDC) and have been described in detail elsewhere.18 In brief, the stroke registry included all patients with a diagnosis of suspected acute stroke or transient ischemic attack admitted to the emergency department (ED) of one of 11 study hospitals during two 3-month periods; November 1, 2002 to January 31, 2003 (Year 1) and November 1,

Results

Of 625 registry patients with acute ischemic stroke, 136 (22%) arrived at the ED within 2.5 hours of symptom onset, 380 (61%) arrived more than 2.5 hours after symptom onset, and 109 (17%) had an indeterminable time of symptom onset. Excluded were 10 patients who arrived within 2.5 hours: 6 patients who received thrombolysis outside of the 3-hour time window (the interval between stroke onset and treatment ranged from 3.15 hours to 6.25 hours), and 4 patients who received an acute intervention

Discussion

In the initial analysis (among 72 patients with ischemic stroke who both arrived within 2.5 hours of symptom onset and had no directly documented contraindication) it was found that only 44% were treated with thrombolysis. Several predictors of nontreatment were identified, including older age and later arrival at the ED after symptom onset. Results were similar after a sensitivity analysis was performed, using data in which eligibility was reclassified based on careful examination and full

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