In-hospital stroke: reperfusion therapy is on the rise, but outcomes are worse

  • Akbik F & al.
  • JAMA Neurol
  • 21 Sep 2020

  • curated by Susan London
  • Clinical Essentials
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Takeaway

  • Use of reperfusion therapy among patients with acute stroke having in-hospital onset more than doubled during a recent decade, but time to use was slower and outcomes were poorer than for patients having out-of-hospital onset.

Why this matters

  • Up to 10.8% of acute ischemic strokes occur among hospitalized patients.
  • Contemporary use of reperfusion therapy and outcomes in this population are unknown.
  • Editorial notes that "treatment can be better" and says the findings support broadening education and relevant protocols to regional stroke systems and healthcare professionals outside of neurology and emergency care. 

Key results

  • Between 2008 and 2018, patients with in-hospital stroke saw increased use of:
    • Intravenous thrombolysis (from 9.1% to 19.1%; P<.001>
    • Endovascular therapy (from 2.5% to 6.9%; P<.001>
  • Among patients receiving intravenous thrombolysis, the in-hospital vs out-of-hospital onset group had longer median times from stroke recognition to:
    • Cranial imaging (33 vs 16 minutes; P<.001>
    • Thrombolysis bolus (81 vs 60 minutes; P<.001>
  • After intravenous thrombolysis, patients with in-hospital onset vs out-of-hospital onset were:
    • Less likely to ambulate independently at discharge (aOR, 0.78; P<.001>
    • More likely to die or be discharged to hospice (aOR, 1.39; P<.001>
  • Findings were similar among patients treated with endovascular therapy.

Study design

  • US retrospective cohort study of patients undergoing reperfusion therapy for stroke 2008-2018 (national registry):
    • 2,170,250 with out-of-hospital onset.
    • 67,493 with in-hospital onset.
  • Main outcomes: trends use of reperfusion therapy, process measures of quality, association of functional outcomes with patient factors.
  • Funding: American Heart Association; Novartis; others.

Limitations

  • Indication for hospital admission was unknown.
  • Potential reporting bias.
  • Unknown generalizability.