Stroke Treatment With Intravenous Tissue-Type Plasminogen Activator
More Proof That Time Is Brain
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Article, see p 128
In this edition of Circulation, Kim and colleagues1 present data from the Get With The Guidelines–Stroke (GWTG-S) registry, with a focus on correlating time to treatment with intravenous tissue-type plasminogen activator (tPA; alteplase) and hospital discharge outcomes. The take-home message is that the sooner a patient is treated with intravenous tPA, the better the odds of having a favorable outcome. This was especially true for the small minority of patients (1.3%) who received intravenous tPA within 60 minutes of stroke onset.
Although intravenous tPA has a treatment window of 4.5 hours (from symptom onset or last known time well to initiation of therapy), only 1.3% of patients began therapy within 60 minutes of stroke onset.1 However, patients receiving therapy within 60 minutes of symptom onset had a 22% to 25% relative increase in being discharged home or being ambulatory at the time of hospital discharge compared with patients who received intravenous tPA beyond 60 minutes. Patient outcomes worsened as the onset-to-treatment time increased. This is not a novel finding; prior studies have found similar correlations.2 Some of this degradation in benefit from tPA followed a linear pattern, whereas at other times the pattern was nonlinear, with a steeper graded association between longer onset-to-treatment time and worse outcomes noted in the first 3 hours after symptom onset
There are several other important findings from this study. Intravenous tPA for stroke has been a US Food and Drug Administration–approved medical therapy for ≈20 years, yet it remains grossly underused. In the Kim et al1 report, only 65 000 of ischemic stroke patients (6.1%) were treated with intravenous alteplase. Although some patients were likely excluded for valid medical reasons (anticoagulant use, exceedingly high blood pressures, recent surgery, or hemorrhage), it is likely that many were …