Time to Thrombolysis and Long-Term Outcomes in Patients With Acute Ischemic Stroke

Background and Purpose: It is well-established that increasing treatment delay reduces the benefits of thrombolysis in patients with acute ischemic stroke. However, most studies focus on short-term outcomes. This study examined long-term outcomes according to time to thrombolysis in patients with first-time ischemic stroke. Methods: In this nationwide cohort study, all Danish patients with first-time ischemic stroke treated with intravenous thrombolysis between 2011 and 2017 and alive at discharge were identified through the Danish Stroke Registry. The association between time from symptom onset to thrombolysis and the long-term rate of the composite of death and recurrent ischemic stroke was examined using multivariable Cox regression and restricted cubic spline analysis. Results: The study population included 6252 patients with first-time ischemic stroke treated with thrombolysis (median age, 69 years [25th–75th percentile 60–78 years], 60% men). The median follow-up was 2.5 years (25th–75th percentile 1.2–4.1 years). The median time to thrombolysis was 138 minutes (25th–75th percentile 101–185 minutes), and the median National Institutes of Health Stroke Scale score at presentation was 5 (25th–75th percentile 3–10). The absolute 3-year risk of the composite outcome was 19.0% (95% CI, 16.4%–21.8%) in the 0 to 90 minute group, 23.3% (21.8%–24.9%) in the 91 to 180 minute group, and 23.8% (21.6%–26.1%) in the 181 to 270 minute group. Compared with thrombolysis within 90 minutes, time to thrombolysis >90 minutes was associated with a higher rate of the composite outcome (91–180 minute: adjusted hazard ratio, 1.25 [95% CI, 1.06–1.48]; 181–270 minutes: adjusted hazard ratio, 1.35 [95% CI, 1.12–1.61]). In restricted cubic spline analysis, the rate of the composite outcome increased with increasing time to thrombolysis and leveled off after 138 minutes. Conclusions: In this nationwide cohort of patients with ischemic stroke, the long-term rate of the composite of death and recurrent ischemic stroke increased with increasing time from symptom onset to initiation of thrombolysis.

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Increasing time to thrombolysis is associated with worse long-term outcomes in patients with ischaemic stroke: a nationwide study

European Heart Journal ◽

10.1093/ehjci/ehaa946.2416 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Yafasova ◽

E.L Fosboel ◽

S.P Johnsen ◽

C Kruuse ◽

J.K Petersen ◽

...

Keyword(s):

Thrombolytic Therapy ◽

Ischaemic Stroke ◽

Acute Ischaemic Stroke ◽

Symptom Onset ◽

Intravenous Thrombolysis ◽

Treatment Delay ◽

Composite Outcome ◽

Long Term Outcomes ◽

First Time

Abstract Background It is well-established that the short-term benefits of intravenous thrombolytic therapy are reduced with increasing treatment delay in patients with acute ischaemic stroke. However, there is a paucity of contemporary data on the association between time from symptom onset to initiation of thrombolysis and long-term outcomes. With improving post-stroke survival in the Western world, data on time to thrombolysis and subsequent long-term outcomes are warranted in order to provide further insight into the importance of time to treatment. Purpose To examine the long-term risk of adverse outcomes according to time from symptom onset to intravenous thrombolytic therapy in patients with acute ischaemic stroke. Methods In this observational cohort study, we identified all patients with first-time ischaemic stroke treated with intravenous thrombolysis between 2011–2015 and alive at discharge through the Danish National Stroke Registry. Patients who received thrombolysis after >270 min were excluded. Using multivariable Cox regression, we examined associations between time from symptom onset to thrombolysis and risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as each of these components separately. Patients were followed until the outcome of interest, emigration, or December 31, 2017. Results Of the 4,313 patients with first-time ischaemic stroke treated with intravenous thrombolysis, 4,119 were alive at discharge (median age 69 years [25th-75th percentile 59–78 years], 60% males). The median follow-up was 3.3 years (25th-75th percentile 2.3–4.7 years). The median time from symptom onset to initiation of thrombolytic therapy was 140 min (25th-75th percentile 106–187 min), and the median National Institutes of Health Stroke Scale score at presentation was 5 (25th-75th percentile 3–10). The unadjusted absolute 3-year risks of the composite outcome, death, recurrent ischaemic stroke, and dementia according to time to thrombolysis are displayed in the figure. Compared with thrombolysis within 90 min, time to thrombolysis >90 min was associated with a higher relative risk of the composite outcome (91–180 min: adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI], 1.13–1.68]; 181–270 min: adjusted HR 1.42 [95% CI 1.15–1.76]). The risks of each component of the composite outcome according to time to thrombolysis were similar to results for the composite endpoint, as illustrated in the figure. Conclusions In this nationwide cohort of patients with acute ischaemic stroke treated with thrombolysis, increasing time from symptom onset to initiation of intravenous thrombolytic therapy was associated with higher long-term risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as all three outcomes separately. These data indicate that long-term outcomes of patients with ischaemic stroke treated with intravenous thrombolysis can be greatly improved by reducing treatment delay. Time to thrombolysis and outcomes Funding Acknowledgement Type of funding source: None

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Early and Continuous Neurologic Improvements after Intravenous Thrombolysis Are Strong Predictors of Favorable Long-term Outcomes in Acute Ischemic Stroke

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2013.07.024 ◽

2013 ◽

Vol 22 (8) ◽

pp. e590-e596 ◽

Cited By ~ 31

Author(s):

Leonard LL. Yeo ◽

Prakash Paliwal ◽

Hock L. Teoh ◽

Raymond C. Seet ◽

Bernard PL. Chan ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Long Term Outcomes

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Long-term Outcomes After Thrombolytic Therapy for Acute Ischemic Stroke

JAMA ◽

10.1001/jama.2020.5269 ◽

2020 ◽

Vol 323 (21) ◽

pp. 2184

Author(s):

Christopher C. Muth

Keyword(s):

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Acute Ischemic Stroke ◽

Long Term Outcomes

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Pneumonia in acute ischemic stroke patients requiring invasive ventilation: Impact on short and long-term outcomes

Journal of Infection ◽

10.1016/j.jinf.2019.06.012 ◽

2019 ◽

Vol 79 (3) ◽

pp. 220-227 ◽

Cited By ~ 4

Author(s):

Etienne de Montmollin ◽

Stephane Ruckly ◽

Carole Schwebel ◽

Francois Philippart ◽

Christophe Adrie ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Invasive Ventilation ◽

Stroke Patients ◽

Long Term Outcomes ◽

Short And Long Term

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O-001 Thrombectomy for acute ischemic stroke patients aged 80 years or older: long-term outcomes in 233 patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2011-010097.1 ◽

2011 ◽

Vol 3 (Suppl_1) ◽

pp. A1-A1

Author(s):

R. Nogueira ◽

W. Smith ◽

T. Jovin ◽

D. Liebeskind ◽

R. Budzik ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Patients ◽

Long Term Outcomes

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Stroke Risks in Adult Survivors of Preterm Birth: National Cohort and Cosibling Study

Stroke ◽

10.1161/strokeaha.120.033797 ◽

2021 ◽

Author(s):

Casey Crump ◽

Jan Sundquist ◽

Kristina Sundquist

Keyword(s):

Ischemic Stroke ◽

Preterm Birth ◽

Large Population ◽

Adult Survivors ◽

Small Sample ◽

Hazard Ratio ◽

Adjusted Hazard Ratio ◽

National Cohort

Background and Purpose: Clinicians will increasingly encounter adult patients who were born preterm and will need to understand their long-term sequelae. Adult survivors of preterm birth have been reported to have increased risks of hypertension and other stroke risk factors. However, their stroke risks have seldom been examined and the findings are discrepant, possibly due to small sample sizes, insufficient follow-up, or survivor bias. We examined whether preterm birth is associated with stroke in a large population-based cohort. Methods: A national cohort study was conducted of all 2 140 866 singletons born in Sweden from 1973 to 1994 who survived to age 18 years, who were followed up for first-time stroke through 2015 (maximum age 43 years). Cox regression was used to examine stroke risks associated with gestational age at birth, adjusting for other perinatal and parental factors. Cosibling analyses assessed for potential confounding by shared familial (genetic or environmental) factors. Results: In 28.0 million person-years of follow-up, 4861 (0.2%) people were diagnosed with stroke. At ages 18 to 43 years, the adjusted hazard ratio for stroke associated with preterm birth (<37 weeks) was 1.26 (95% CI, 1.12–1.43; P <0.001), and further stratified was 1.42 (1.11–1.81; P =0.005) for early preterm (22–33 weeks) and 1.22 (1.06–1.40; P =0.004) for late preterm (34–36 weeks), compared with full-term (39–41 weeks). Positive associations were found with both hemorrhagic stroke (early preterm: adjusted hazard ratio, 1.42 [95% CI, 1.04–1.94]; any preterm: 1.15 [0.97–1.35]) and ischemic stroke (early preterm: adjusted hazard ratio, 1.33 [95% CI, 0.87–2.03]; any preterm: 1.31 [1.07–1.60]). These findings were similar in men and women and only partially explained by shared determinants of preterm birth and stroke within families. Conclusions: In this large national cohort, preterm birth was associated with increased risks of both hemorrhagic and ischemic stroke in adulthood. Preterm birth survivors need early preventive evaluation and long-term clinical follow-up to reduce their lifetime risk of stroke.

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Angina Severity at the Time of Revascularization in Patients With Diabetes Mellitus and Its Association With Long-term Outcomes: A Multicenter Cohort Study.

10.21203/rs.3.rs-892501/v1 ◽

2021 ◽

Author(s):

Nozomi Niimi ◽

Satoshi Shoji ◽

Mitsuaki Sawano ◽

Nobuhiro Ikemura ◽

Yasuyuki Shiraishi ◽

...

Keyword(s):

Diabetes Mellitus ◽

Heart Failure ◽

Hazard Ratio ◽

Adjusted Hazard Ratio ◽

Contributing Factors ◽

Long Term Outcomes ◽

Coronary Syndrome ◽

Significant Difference ◽

Patients With Diabetes

Abstract Background: While angina severity is pertinent in determining the management strategy for patients with stable ischemic heart disease (SIHD), its contributing factors and prognostic effect remain unclear, particularly in patients with diabetes mellitus (DM). Methods: From a multicenter percutaneous coronary intervention (PCI) registry, 1,911 consecutive SIHD patients without previous revascularization or heart failure between 2008 and 2015 were analyzed. Angina severity was assessed by the Canadian Cardiovascular Society (CCS) functional classification at the time of PCI. We assessed the contributing factors of CCS III/IV angina. Further, the association between CCS III/IV angina and subsequent occurrence of major adverse cardiac and cerebrovascular events (MACCE: all-cause death, acute coronary syndrome, heart failure, and stroke) within 2 years were analyzed in patients with DM and without DM.Results: A total of 771 SIHD patients (40.3% of all SIHD patients) had DM at the time of revascularization. In the total cohort, 52.4% had CCS I/II, and 13.0% had CCS III/IV angina, with less prevalence of CCS III/IV angina in patients with DM than in those without DM (11.3% vs. 14.2%, P<0.001). In patients with DM, the prevalence of unprotected left main coronary trunk lesions and proximal left anterior descending lesion increased with angina severity. The presence of severe angina at the time of PCI was associated with MACCE in patients with DM (adjusted hazard ratio 1.93; [95% CI 1.01, 3.71]; P=0.047), while no significant difference in those without DM (adjusted hazard ratio 0.82; [95% CI 0.42, 1.59]; P=0.55).Conclusions: In SIHD patients with DM that underwent PCI, severe angina at the time of revascularization was associated with complex coronary anatomies and long-term outcomes. These findings underscore the importance of evaluating angina-related health status while considering revascularization in SIHD patients with DM.

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Abstract WP94: Higher Mortality in Slow Blood Pressure Droppers: Blood Pressure Trajectory Groups of 1-Year After Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.wp94 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Keon-Joo Lee ◽

Beom Joon Kim ◽

Moon-Ku Han ◽

Joon-Tae Kim ◽

Kang Ho Choi ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Time Course ◽

Information Criterion ◽

Stroke Recurrence ◽

Stroke Patients ◽

Composite Events

Introduction: Although the effect of blood pressure in post-stroke outcome is well recognized, the long-term time course of BP following acute ischemic stroke and it’s influence to outcomes have not been well elucidated. Method: From a multicenter prospective registry of acute ischemic stroke patients, a total of 5,514 patients with measurement of systolic blood pressure (SBP) in more than 2 of 7 prespecified time points up to 1 year after symptom onset were analyzed. The patients were grouped according to longitudinal SBPs of each patient using a group-based trajectory model, and number of groups were determined by the optimal delta-Bayesian Information Criterion. Outcome measures, which were stroke recurrence, mortality and composite of each events along with myocardial infarction were prospectively collected up to 1 year after symptom onset. Results: Patients were categorized into four groups according to their SBP trajectories: low (27.0%), moderate (59.5%), persistently high (1.2%), and slowly dropping (12.4%). After adjustment for pre-determined covariates, there were higher risk of stroke recurrence in persistently high SBP group (hazard ratio (HR), 2.28 [95% confidence interval (CI), 1.01-5.12]). Mortality was higher only in the slowly dropping SBP group (HR, 1.50 [95% CI, 1.09-2.05]). Composite events were higher in both persistently high (HR, 1.96 [95% CI, 1.02-3.75]) and slowing dropping (HR, 1.54 [95% CI, 1.18-2.00]) SBP groups. Conclusion: There were a group of patterns in long-term longitudinal SBP changes after acute ischemic stroke. Especially, slow BP droppers might have a distinct nature with higher mortality and would be a target for future investigations.

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