Troponin elevation predicts critical care needs and in-hospital mortality after thrombolysis in white but not black stroke patients

Background: Among patients hospitalized for acute ischemic stroke, abnormal serum troponins are associated with higher risk of short-term mortality. However, most findings have been reported from European hospitals. Whether troponin elevation after stroke is independently associated with death among a more heterogeneous US population remains unclear. Furthermore, only a few studies have evaluated the association between the magnitude of troponin elevation and subsequent mortality, patterns of dynamic troponin changes over time, or whether troponin elevation is related to specific causes of death. Methods: Using data collected in the American Heart Association's ‘Get With The Guidelines' stroke registry between 2008 and 2012 at a tertiary care US hospital, we used logistic regression to evaluate the independent relationship between troponin elevation and mortality after adjusting for demographic and clinical characteristics. We then assessed whether the magnitude of troponin elevation was related to in-hospital mortality by calculating mortality rates according to tertiles of peak troponin levels. Dynamic troponin changes over time were evaluated as well. To better understand whether troponin elevation identified patients most likely to die due to a specific cause of death, investigators blinded from troponin values reviewed all in-hospital deaths, and the association between troponin elevation and mortality was evaluated among patients with cardiac, neurologic, or other causes of death. Results: Of 1,145 ischemic stroke patients, 199 (17%) had elevated troponin levels. Troponin-positive patients had more cardiovascular risk factors, more intensive medical therapy, and greater use of cardiac procedures. These individuals had higher in-hospital mortality rates than troponin-negative patients (27 vs. 8%, p < 0.001), and this association persisted after adjustment for 13 clinical and management variables (OR 4.28, 95% CI 2.40-7.63). Any troponin elevation was associated with higher mortality, even at very low peak troponin levels (mortality rates 24-29% across tertiles of troponin). Patients with persistently rising troponin levels had fewer anticoagulant and antiatherosclerotic therapies, with markedly worse outcomes. Furthermore, troponin-positive patients had higher rates of all categories of death: neurologic (17 vs. 7%), cardiac (5 vs. <1%), and other causes of death (5 vs. <1%; p < 0.001 for all comparisons). Conclusions: Ischemic stroke patients with abnormal troponin levels are at higher risk of in-hospital death, even after accounting for demographic and clinical characteristics, and any degree of troponin elevation identifies this higher level of risk. Troponins that continue to rise during the hospitalization identify stroke patients at markedly higher risk of mortality, and both neurologic and non-neurologically mediated mortality rates are higher when troponin is elevated.

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Safety Trial of Low-Intensity Monitoring After Thrombolysis: Optimal Post Tpa-Iv Monitoring in Ischemic STroke (OPTIMIST)

The Neurohospitalist ◽

10.1177/1941874419845229 ◽

2019 ◽

Vol 10 (1) ◽

pp. 11-15 ◽

Cited By ~ 8

Author(s):

Roland Faigle ◽

Jaime Butler ◽

Juan R. Carhuapoma ◽

Brenda Johnson ◽

Elizabeth K. Zink ◽

...

Keyword(s):

Critical Care ◽

Vital Signs ◽

Intravenous Thrombolysis ◽

Neurological Status ◽

Stroke Patients ◽

Care Needs ◽

Open Label ◽

Low Intensity ◽

Monitoring Protocol ◽

Care Intervention

Background and Purpose: At present, stroke patients receiving intravenous thrombolysis (IVT) undergo monitoring of their neurological status and vital signs every 15 minutes for the first 2 hours, every 30 minutes for the next 6 hours, and every hour thereafter up to 24 hours post-IVT. The present study sought to prospectively evaluate whether post-IVT stroke patients with low risk for complications may safely be cared for utilizing a novel low-intensity monitoring protocol. Methods: In this pragmatic, prospective, single-center, open-label, single-arm safety study, we enrolled 35 post-IVT stroke patients. Adult patients were eligible if their NIH Stroke Scale (NIHSS) was less than 10 at the time of presentation, and if they had no critical care needs by the end of the IVT infusion. Patients underwent a low-intensity monitoring protocol during the first 24 hours after IVT. The primary outcome was need for a critical care intervention in the first 24 hours after IVT. Results: The median age was 54 years (range: 32-79), and the median pre-IVT NIHSS was 3 (interquartile range [IQR]: 1-6). None of the 35 patients required transfer to the intensive care unit or a critical care intervention in the first 24 hours after IVT. The median NIHSS at 24 hours after IVT was 1 (IQR: 0-3). Four (11.4%) patients were stroke mimics, and the vast majority was discharged to home (82.9%). At 90 days, the median NIHSS was 0 (IQR: 0-1), and the median modified Rankin Scale was 0 (range: 0-6). Conclusion: Post-IVT stroke patients may be safely monitored in the setting of a low-intensity protocol.

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ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients

Critical Care ◽

10.1186/s13054-016-1195-7 ◽

2015 ◽

Vol 20 (1) ◽

Cited By ~ 6

Author(s):

Roland Faigle ◽

Elisabeth B. Marsh ◽

Rafael H. Llinas ◽

Victor C. Urrutia ◽

Rebecca F. Gottesman

Keyword(s):

Critical Care ◽

Stroke Patients ◽

Care Needs

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Registered nurses’ role experiences of caring for older stroke patients: a qualitative study

BMC Nursing ◽

10.1186/s12912-021-00626-y ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Wei Cheng ◽

Jiong Tu ◽

Xiaoyan Shen

Keyword(s):

Nursing Education ◽

Older People ◽

Registered Nurses ◽

Elderly Care ◽

The Elderly ◽

Working Environment ◽

Structured Interviews ◽

Stroke Patients ◽

Care Needs ◽

Nursing Clinical Practice

Abstract Background With China’s population ageing rapidly, stroke is becoming one of the major public health problems. Nurses are indispensable for caring for older patients with acute and convalescent stroke, and their working experiences are directly linked to the quality of care provided. The study aims to investigate registered nurses’ experiences of caring for older stroke patients. Methods A qualitative descriptive design was adopted. Data were collected via semi-structured interviews with 26 registered nurses about their lived experiences of caring for older stroke patients. Thematic analysis was used to analyze the data. Results Two main themes were identified. First, the nurses identified an obvious gap between their ideal role in elderly care and their actual practice. The unsatisfactory reality was linked to the practical difficulties they encountered in their working environment. Second, the nurses expressed conflicting feelings about caring for older stroke patients, displaying a sense of accomplishment, indifference, annoyance, and sympathy. Caring for older stroke patients also affects nurses psychologically and physically. The nurses were clear about their own roles and tried their best to meet the elderly people’s needs, yet they lack time and knowledge about caring for older stroke patients. The factors influencing their working experiences extend beyond the personal domain and are linked to the wider working environment. Conclusions Sustaining the nursing workforce and improving their working experiences are essential to meet the care needs of older people. Understanding nurses’ lived working experiences is the first step. At the individual level, nurse mangers should promote empathy, relieve anxiety about aging, and improve the job satisfaction and morale of nurses. At the institutional level, policymakers should make efforts to improve the nursing clinical practice environment, increase the geriatric nursing education and training, achieve a proper skill mix of the health workforce, and overall attract, prepare and sustain nurses regarding caring for older people in a rapidly aging society.

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Resting Heart Rate and In-Hospital Mortality in Acute Ischemic Stroke Patients With and Without Atrial Fibrillation

Circulation Journal ◽

10.1253/circj.cj-19-0946 ◽

2020 ◽

Vol 84 (4) ◽

pp. 656-661

Author(s):

Qiao Han ◽

Chunyuan Zhang ◽

Shoujiang You ◽

Danni Zheng ◽

Chongke Zhong ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Rate ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Resting Heart Rate ◽

Stroke Patients

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Potential Risk and Protective Factors for In-Hospital Mortality in Hyperacute Ischemic Stroke Patients

The Kaohsiung Journal of Medical Sciences ◽

10.1016/s1607-551x(08)70116-5 ◽

2008 ◽

Vol 24 (4) ◽

pp. 190-196 ◽

Cited By ~ 4

Author(s):

Chien-Hsun Li ◽

Gim-Thean Khor ◽

Chun-Hung Chen ◽

Poyin Huang ◽

Ruey-Tay Lin

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Protective Factors ◽

Potential Risk ◽

Risk And Protective Factors ◽

Stroke Patients

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Hospital Mortality, Length of Stay, and Preventable Complications Among Critically Ill Patients Before and After Tele-ICU Reengineering of Critical Care Processes

JAMA ◽

10.1001/jama.2011.697 ◽

2011 ◽

Vol 305 (21) ◽

pp. 2175 ◽

Cited By ~ 285

Author(s):

Craig M. Lilly

Keyword(s):

Critical Care ◽

Length Of Stay ◽

Hospital Mortality ◽

Critically Ill ◽

Critically Ill Patients ◽

Care Processes ◽

Before And After

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Abstract 3418: Acute Care Nurse Practicioner Led Critical Care Transport Team Leads to Improved Door to Imaging Time in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.43.suppl_1.a3418 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Michelle M Winfield ◽

Julie A McNeil ◽

Stephanie L Steiner ◽

Christopher F Manacci ◽

Damon Kralovic ◽

...

Keyword(s):

Critical Care ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Patient Outcomes ◽

Care Transitions ◽

Cleveland Clinic ◽

Stroke Patients ◽

Time Intervals ◽

Care Nurse ◽

Transport Team

Background: In evaluating the acute ischemic stroke (AIS) patient, targeting time intervals for imaging and treatment times are paramount in optimizing outcomes. Initial evaluation by skilled providers who can facilitate the extension of a tertiary care facility can positively influence patient outcomes. A collaborative approach with a hospital based Critical Care Transport (CCT) Team can extend primary stroke program care out to a referring facility’s bedside. In the Cleveland Clinic Health System, the suspicion of a large vessel occlusion causing AIS in patients at an outside hospital triggers an “Auto Launch” process, bypassing typical transfer processes to expedite care transitions for patients with time sensitive emergencies. Referring facilities contact a CCT Coordinator, with immediate launching of the transport team that consists of an Acute Care Nurse Practitioner (ACNP) who evaluates the patient at outside facility, performs NIHSS and transitions the patient directly to CT/MRI upon return to Cleveland Clinic facility. Patient is met by the Stroke Neurology Team at CT scanner for definitive care. A CCT Team with an ACNP on board can augment not only door to CT and MRI times, but also time to evaluation by a stroke neurologist and time to intervention, bypassing the Emergency Department upon their arrival and proceeding directly to studies and/or time sensitive intervention as appropriate. Objective: To describe a stroke program with a coordinated approach with a CCT Team to facilitate rapid care transitions as well as decreased time to imaging in patients with AIS by having an ACNP on board during transport and throughout the continuum of care. Methods: A retrospective audit of a database of patients undergoing hyperacute evaluation of acute ischemic stroke symptoms from April 30, 2010 to July 31, 2011 was performed. Demographic information, types of imaging performed, hyperacute therapies administered and time intervals to imaging modalities and treatment were collected and analyzed. Results: 107 patients total, 28 males, and 36 females with a mean age of 70 were included in the analysis. 60% [64] of patients transferred via the CCT Team over 26.42 average nautical miles. The mean time of call to arrival was 1 hr and 19 min. The CCT Team monitored tPA infusion in 27 patients and initiated tPA infusion in 2 patients. 64 patients had CT imaging performed and 64 had MRI performed following the CT. [The average door to CT completion was 22 min, the average door to MRI completion was 1 hr and 29 min, compared to 1 hr and 8 min and 2 hr and 36 min, respectively, in patients not arriving by CCT Team], p<0.05. Conclusion: Collaboration between the Stroke Neurology Team and CCT Team has allowed acute ischemic stroke patients to be taken directly to CT/MRI scanner, allowing for rapid evaluation, definitive treatment decisions, and the potential for improved patient outcomes by decreasing the door to imaging time.

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Abstract T P243: Mortality Among Transferred Hemorrhagic Stroke Patients in United States: An Analysis From National Database

Stroke ◽

10.1161/str.45.suppl_1.tp243 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Malik M Adil ◽

Shyam Prabhakaran

Keyword(s):

Hospital Mortality ◽

Hemorrhagic Stroke ◽

Inpatient Rehabilitation ◽

National Database ◽

Stroke Patients ◽

Discharge Outcomes ◽

Hospital Transfer ◽

Transferred Patients ◽

Surgical Treatments ◽

Acute Rehabilitation

Background: Hemorrhagic stroke patients may require inter-facility transfer for higher level of care. Limited data are available on outcome of transferred patients. Objective: To determine in-hospital mortality and discharge outcomes among transferred hemorrhagic stroke patients. Methods: Data from all patients admitted to US hospitals between 2008 and 2011 with a primary discharge diagnosis of hemorrhagic stroke [intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)] were identified by ICD-9 codes (ICH: 431; SAH: 430). In separate models for ICH and SAH using logistic regression, the odds ratio (OR) and 95% confidence intervals (CI) for in-hospital mortality and good outcome (discharge home or inpatient rehabilitation) among transfer vs. non-transfers were estimated, after adjusting for potential confounders. Results: Of 290,395 patients with ICH, 48,749 (16.8%) arrived by inter-hospital transfer; for SAH, 25,726 (33%) of 78,156 were transfers. In-hospital mortality was lower among ICH transfers (21.2% vs. 23.2%; p=0.004). In adjusted analyses, in-hospital mortality was not significantly different (p=0.20) while discharge to home or inpatient rehabilitation was more likely among transferred ICH patients (OR 1.1, 95% CI 1.0-1.2, p=0.05). In-hospital mortality was lower for SAH transfers (17.4% vs. 22.9%, p<0.001) and remained significant in adjusted analyses (OR 0.7, 95% CI 0.6-0.8). Transferred SAH patients were also more likely to be discharged to home or inpatient rehabilitation (OR 1.2, 95% CI 1.1-1.4, p<0.001). Coiling and clipping procedures were significantly more common in SAH transferred patients while cerebral angiography, mechanical ventilation and gastrostomy were significantly higher in both ICH and SAH transfer patients. Conclusion: While ICH patients arriving by transfer have similar mortality as non-transfers, they are more likely to be discharged to home or acute rehabilitation. For SAH, transfer confers both mortality and outcome benefit. Definitive surgical treatments and aggressive medical supportive care at receiving hospitals may mediate the benefits of inter-hospital transfer in hemorrhagic stroke patients.

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