Study highlights:

• In 2001 and 2004, only about one-third of ischemic stroke patients got to the hospital within two hours of symptom onset, which likely would make them eligible for a clot-buster drug that significantly reduces stroke effects and permanent disability.
• Compared to 2001, in 2004 significantly more eligible stroke patients were treated with tPA once they got to one of the hospitals – all of which were academic medical centers.
• Blacks were about half as likely as whites to arrive at the hospital within two hours.

DALLAS, Oct. 1, 2009 — Hospitals were more likely to administer the clot-buster tissue plasminogen activator (tPA) in 2004 than in 2001 — but the proportion of stroke patients arriving at the hospital in time to receive it didn’t improve, according to research reported in Stroke: Journal of the American Heart Association.

Researchers reviewed records of 428 patients from 2001 and 481 patients from 2004 who were treated at one of more than 30 academic medical centers participating in the University HealthSystem Consortium Ischemic Stroke Benchmarking Project. They found that:

• In both years, only about 37 percent of patients arrived within two hours of the start of stroke symptoms.
• Black patients were 44 percent less likely than white patients to arrive at the hospital within two hours of symptom onset.
• Patients with severe symptoms were more than twice as likely to arrive within two hours compared to those with mild to moderate symptoms.
• Patients with a history of heart disease who called an ambulance were more likely to arrive within two hours.
• Only 14 percent of eligible stroke patients received the therapy at hospitals in 2001 but 37.5 percent got it in 2004.

The evidence may indicate that hospitals’ systems of stroke care could be improving, but patient recognition of symptoms is not, said Judith H. Lichtman, Ph.D., M.P.H., lead author of the study.

tPA is the only drug approved by the U.S. Food and Drug Administration for the urgent treatment of ischemic stroke. If given within three hours of stroke symptom onset, tPA has been shown to significantly reduce the effects of stroke, including permanent disability.

In 2009, the American Heart Association/American Stroke Association recommended that tPA be given to certain patients up to 4.5 hours after stroke symptoms begin.

“One of the biggest challenges for stroke care is to make sure that people get to the hospital as soon as possible after stroke symptom onset, so the therapy has the best chance of helping,” said Lichtman, an associate professor in the epidemiology and public health department at Yale University School of Medicine in New Haven, Conn. “Until the recent AHA Scientific Statement, the drug could only be given within 3-hours after symptoms began, which meant that they needed to get to the hospital within 2-hours to have the diagnostic tests needed to assess eligibility for tPA.”

To determine if the message was getting out to consumers and healthcare systems, Lichtman and colleagues reviewed consecutive charts for patients who arrived at one of more than 30 academic medical centers within 48 hours of symptom onset and compared this snapshot in 2001 with data from 2004. Two hours from symptom onset to hospital arrival was chosen to provide adequate time to perform tests that determine tPA eligibility. They found that slightly more than one-third of stroke patients presented to the hospital within a time window to be eligible for tPA.

“The other side of that is two-thirds of patients are not even making it inside the hospital door to be eligible for tPA, which is a great public health concern,” Lichtman said. “That percentage did not improve over time — from ’01 to ’04.

“This study shows us that making a change is a complex problem. We need to get better at educating the public about how to recognize the signs and symptoms of stroke. This will mean not only creating awareness but also changing behaviors, so people who are think that they are having a stroke call 9-1-1 quickly.”

Educational campaigns targeted to specific high-risk groups — such as the American Stroke Association’s Power To End Stroke that raises awareness about the importance of stroke among African Americans — “may be critical to these efforts,” Lichtman said.

“We need to continue this positive trend with healthcare systems, so prehospital and in-hospital providers continue to improve on tPA administration for stroke.”

The warning signs of stroke are:
• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body;
• Sudden confusion, trouble speaking or understanding;
• Sudden trouble seeing in one or both eyes;
• Sudden trouble walking, dizziness, loss of balance or coordination; and
• Sudden, severe headache with no known cause.

Co-authors are Emi Watanabe, M.P.H.; Norrina B. Allen, Ph.D, M.P.H.; Sara B. Jones, M.P.H.; Jackie Dostal, M.B.A.; and Larry B. Goldstein, M.D. Author disclosures are on the manuscript.

The study was partially funded by the Centers for Disease Control and Prevention.

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Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and device corporations are available at www.americanheart.org/corporatefunding.  

NR09 – 1122 (Stroke/Lichtman)
 

Additional Resources:
AHA/ASA Science Advisory: Expansion of the Time Window for Treatment of Acute Ischemic Stroke With Intravenous Tissue Plasminogen Activator
ASA Power To End Stroke campaign: http://www.powertoendstroke.org