MedicalResearch.com Interview with:
Dr. Gregg C. Fonarow MD
Director, Ahmanson-UCLA Cardiomyopathy Center
Professor, Department of Medicine
Associate Chief, Cardiology
David Geffen School of Medicine Los Angeles, CA
MedicalResearch.com: What are the main findings of the study?
Dr. Fonarow: This study examined data from hospitals that have adopted the American Heart Association/ American Stroke Association’s national quality initiative, Target: Stroke, which aims to increase the number of stroke patients treated with clot-busting drugs for ischemic stroke within 60 minutes or less after hospital arrival. Initiated nationwide in 2010, Target: Stroke provided 10 key strategies as well as tools to facilitate timely tPA administration, as well as additional approaches to improve stroke care and outcome.
Data from 71,169 tPA-treated stroke patients at 1,030 hospitals participating in Target: Stroke were analyzed to compared the time to treatment and incidence of complications before implementation, from 2003 to 2009, to the post-implementation years, from 2010 to 2013.
This study found that the percentage of patients treated within the recommended timeframe increased from less than one-third before Target: Stroke to more than half afterwards. The Target: Stroke program goal of 50 percent or more of patients having door-to-needle times within 60 minutes was successfully achieved. In addition, the average time to treatment dropped by 15 minutes, from 74 to 59 minutes.
Faster treatment was associated with lower rates of complications, including death. Before Target: Stroke, 9.9% of stroke patients died in the hospital, compared to 8.3% of patients treated after the initiative started, a difference which was statistically significant. In addition, patients treated by Target: Stroke strategies were less likely to develop the complication of symptomatic intracranial hemorrhage.
MedicalResearch.com: Were any of the findings unexpected?
Dr. Fonarow: While there have been concerns that attempting to achieve shorter DTN times may lead to rushed assessments, inappropriate patient selection, dosing errors, and greater likelihood of complications, our findings suggest that more rapid reperfusion therapy in acute ischemic stroke is feasible and, importantly, can be achieved not only without increasing rates of symptomatic intracranial hemorrhage, but with actual reductions in complications and improvements in overall tPA treatment rates.
While the clinical outcome improvements observed in this study and their magnitude are consistent with those expected with more timely tPA treatment based prior studies in acute ischemic stroke, these findings stand in contradistinction to an analysis involving 515 hospitals and 96,738 admissions in which reductions in door-to-balloon times in ST-segment elevation myocardial infarction were not accompanied by any changes in short-term mortality rates. This difference potentially reflects greater sensitivity of the brain versus the heart to functionally relevant ischemia progression over time spans of several minutes.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Fonarow: The Target: Stroke quality improvement initiative was highly successful in improve stroke care and clinical outcomes at the national level. These findings also further reinforce the importance and clinical benefits of faster administration of intravenous tPA. By showing that the timeliness of tPA administration can be improved at the national level, these findings also support further expansion of the Target: Stroke initiative.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Fonarow: The American Heart Association/American Stroke Association will be launching Target: Stroke Phase II to further improve the timeliness of tPA administration and clinical outcomes for acute ischemic stroke. The Phase II Program goal is to increase the proportion of patients with door-to-needle times within 60 minutes to 75% and to achieve door-to-needle times of 45 minutes or less in at least 50% of patients.
Door-to-Needle Times for Tissue Plasminogen Activator Administration and Clinical Outcomes in Acute Ischemic Stroke Before and After a Quality Improvement Initiative
Gregg C. Fonarow MD, Xin Zhao MS, Eric E. Smith MD, MPH, Jeffrey L. Saver MD, Mathew J. Reeves PhD, Deepak L. Bhatt MD, MPH, Ying Xian MD, PhD, Adrian F. Hernandez MD, MHS, Eric D. Peterson MD, MPH, Lee H. Schwamm MD
JAMA. 2014;311(16):1632-1640. doi:10.1001/jama.2014.3203