The "golden hour" and acute brain ischemia: presenting features and lytic therapy in >30,000 patients arriving within 60 minutes of stroke onset

Abstract

Background and purpose: The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent.

Methods: The Get With the Guidelines-Stroke database was analyzed to characterize ischemic stroke patients arriving at hospital Emergency Departments within 60 minutes of the last known well time from April 1, 2003, to December 30, 2007.

Results: During the 4.75-year study period, among 253 148 ischemic stroke patients arriving directly by ambulance or private vehicle at 905 hospital Emergency Departments, 106 924 (42.2%) had documented, exact last known well times. Onset to door time was <or=60 minutes in 30 220 (28.3%), 61 to 180 minutes in 33 858 (31.7%), and >180 minutes in 42 846 (40.1%). Features most strongly distinguishing the patients arriving at <or=60, 61 to 180, and >180 minutes were greater stroke severity (median National Institutes of Health Stroke Scale score, 8.0 vs 6.0 vs 4.0, P<0.0001) and more frequent arrival by ambulance (79.0%. vs 72.2% vs 55.0%, P<0.0001). Compared with patients arriving at 61 to 180 minute, "golden hour" patients received intravenous thrombolytic therapy more frequently (27.1% vs 12.9%; odds ratio=2.51; 95% CI, 2.41-2.61; P<0.0001), but door-to-needle time was longer (mean, 90.6 vs 76.7 minutes, P<0.0001). A door-to-needle time of <or=60 minutes was achieved in 18.3% of golden hour patients.

Conclusions: At Get With the Guidelines-Stroke hospital Emergency Departments, more than one quarter of patients with documented onset time and at least one eighth of all ischemic stroke patients arrived within 1 hour of onset, where they received thrombolytic therapy more frequently but more slowly than late arrivers. These findings support public health initiates to increase early presentation and shorten door-to-needle times in patients arriving within the golden hour.

Figure 1

Relation of onset to door versus door to needle times among all IV TPA within 3 hours treated ischemic stroke patients (n=11883). Mean OTD time was 56.3 (± 28.5) and DTN time 84.1 (± 29.0). The correlation coefficient was -0.30.

Figure 2

Distribution of door to needle times among patients arriving in ED within first 60 minutes after onset. Bracket shows proportion treated within DTN ≤ 60 minutes stretch target.