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. 2020 Dec 1;77(12):1486-1495.
doi: 10.1001/jamaneurol.2020.3362.

Trends in Reperfusion Therapy for In-Hospital Ischemic Stroke in the Endovascular Therapy Era

Feras Akbik  1 , Haolin Xu  2 , Ying Xian  2 , Shreyansh Shah  2 , Eric E Smith  3 , Deepak L Bhatt  4   5 , Roland A Matsouaka  2   6 , Gregg C Fonarow  7 , Lee H Schwamm  8
Affiliations

Trends in Reperfusion Therapy for In-Hospital Ischemic Stroke in the Endovascular Therapy Era

Feras Akbik et al. JAMA Neurol. .

Abstract

Importance: A significant proportion of acute ischemic strokes occur while patients are hospitalized. Limited contemporary data exist on the utilization rates of intravenous thrombolysis or endovascular therapy for in-hospital stroke.

Objective: To use a national registry to examine temporal trends in the use of intravenous and endovascular reperfusion therapies for treatment of in-hospital stroke.

Design, setting, and participants: This retrospective cohort study analyzed data from 267 956 patients who underwent reperfusion therapy for stroke with in-hospital or out-of-hospital onset reported in the Get With the Guidelines-Stroke national registry from January 2008 to September 2018.

Exposures: In-hospital onset vs out-of-hospital onset of stroke symptoms.

Main outcomes and measures: Temporal trends in the use of reperfusion therapy, process measures of quality, and the association between functional outcomes and key patient characteristics, comorbidities, and treatments.

Results: Of 67 493 patients with in-hospital stroke onset, this study observed increased rates of vascular risk factors (standardized mean difference >10%) but no significant differences in age or sex in patients undergoing intravenous thrombolysis only (mean [interquartile range {IQR}] age, 72 [80-62] y; 53.2% female) or those undergoing endovascular therapy (mean [IQR] age, 69 [59-79] y; 49.8% female). Of these patients, 10 481 (15.5%) received intravenous thrombolysis and 2494 (3.7%) underwent endovascular therapy. Compared with 2008, in 2018 the proportion of in-hospital stroke among all stroke hospital discharges was higher (3.5% vs 2.7%; P < .001), as was use of intravenous thrombolysis (19.1% vs 9.1%; P < .001) and endovascular therapy (6.4% vs 2.5%; P < .001) in patients with in-hospital stroke, with a significant increase in endovascular therapy in mid-2015 (P < .001). Compared with patients who received intravenous thrombolysis for out-of-hospital stroke onset, those with in-hospital onset were associated with longer median (IQR) times from stroke recognition to cranial imaging (33 [18-60] vs 16 [9-26] minutes; P < .001) and to thrombolysis bolus (81 [52-125] vs 60 [45-84] minutes; P < .001). In adjusted analyses, patients with in-hospital stroke onset who were treated with intravenous thrombolysis were less likely to ambulate independently at discharge (adjusted odds ratio, 0.78; 95% CI, 0.74-0.82; P < .001) and were more likely to die or to be discharged to hospice (adjusted odds ratio, 1.39; 95% CI, 1.29-1.50; P < .001) than patients with out-of-hospital onset who also received intravenous thrombolysis treatment. Comparisons among patients treated with endovascular therapy yielded similar findings.

Conclusions and relevance: In this cohort study, in-hospital stroke onset was increasingly reported and treated with reperfusion therapy. Compared with out-of-hospital stroke onset, in-hospital onset was associated with longer delays to reperfusion and worse functional outcomes, highlighting opportunities to further care for patients with in-hospital stroke onset.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Xian reported research grants provided to the Duke Clinical Research Institute from Genentech and receiving honoraria from Boehringer Ingelheim. Dr Smith reported receiving personal fees from Alnylam Pharmaceuticals, Biogen, and UpToDate outside the submitted work. Dr Bhatt reported receiving nonfinancial support from the American Heart Association; receiving grants from Abbott, Afimmune, Amarin Corporation, Amgen, AstraZeneca, Bristol Myers Squibb, Chiesi, Eisai, Eli Lilly and Company, Ethicon, Fractyl, Ironwood Pharmaceuticals, Lexicon Pharmaceuticals, Medtronic, Roche, Sanofi-Aventis, The Medicines Company, and Regeneron; receiving grants and other (see below for definitions of “other”) from Cardax, Forest Laboratories/AstraZeneca, Idorsia, Ischemix, Pfizer, PhaseBio, PLx Pharma Inc, and Synaptic Pharmaceuticals; receiving personal fees from Bayer, Belvoir Publications, CellProthera, Cleveland Clinic, Contego Medical, CSL Behring, Duke Clinical Research Institute, Elsevier, Ferring Pharmaceuticals, Harvard Clinical Research Institute (now Baim Institute for Clinical Research), HMP Global, Journal of the American College of Cardiology, Level Ex, Mayo Clinic, Population Health Research Institute, Medtelligence/ReachMD, MJH Life Sciences, Icahn School of Medicine at Mount Sinai, Slack Publications, and TobeSoft, WebMD; receiving personal fees and nonfinancial support from the American College of Cardiology (ACC) and the Society of Cardiovascular Patient Care (now called ACC Accreditation Services); receiving grants, personal fees, and other from Boehringer Ingelheim outside the submitted work; being on the advisory boards of Cardax, CellProthera, Cereno Scientific AB, Elsevier PracticeUpdate Cardiology, Level Ex, Medscape Cardiology, PhaseBio, PLx Pharma Inc, and Regado Biosciences; being on the boards of directors for Boston VA Research Institute, ACC Accreditation Services, and TobeSoft; being the chair of the American Heart Association Quality Oversight Committee; being on the Data Monitoring Committee of the Baim Institute for Clinical Research (for the PORTICO trial, funded by St Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Icahn School of Medicine at Mount Sinai (for the ENVISAGE trial, funded by Daiichi Sankyo), and Population Health Research Institute; receiving honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org; vice-chair, ACC Accreditation Committee), Baim Institute for Clinical Research (RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (editor in chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor; associate editor), K2P (cochair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (continuing medical education steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national coleader, funded by Bayer), Slack Publications (chief medical editor, Cardiology Today’s Intervention), ACC Accreditation Services (secretary/treasurer), and WebMD (continuing medical education steering committees); being a deputy editor for Clinical Cardiology; being the Chair for the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry Steering Committee, and for the VA Clinical Assessment, Reporting, and Tracking Research and Publication Committee; receiving research funding from Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Eli Lilly and Company, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi-Aventis, Synaptic Pharmaceuticals, and The Medicines Company; receiving royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); being a site coinvestigator for Biotronik, Boston Scientific, CSI Specialty Group, St Jude Medical (now Abbott), and Svelte; being a trustee for the American College of Cardiology; and providing unfunded research for FlowCo, Merck & Co, Novo Nordisk, and Takeda. Dr Fonarow reported receiving grants from the Patient Centered Outcome Research Institute outside the submitted work; being a Get With The Guidelines steering committee member; and being employed by UCLA Regent, which holds a patent on an endovascular therapy device. Dr Schwamm reported receiving personal fees from Diffusion Pharmaceuticals, Life Image, Massachusetts Department of Public Health, Medtronic, and Penumbra Inc; receiving grants and personal fees from Genentech; and receiving grants from the National Institute of Neurological Disorders and Stroke (NINDS) outside the submitted work. Dr Schwamm also reported the following relationships relevant to research grants or companies that manufacture products for thrombolysis or thrombectomy even if the interaction involves nonthrombolysis products: scientific consultant regarding trial design and conduct to Genentech (late-window thrombolysis) and a member of the steering committee (TIMELESS, NCT03785678); consultant on user interface design and usability to LifeImage; stroke systems of care to the Massachusetts Department of Public Health; member of a data safety monitoring board for Penumbra Inc (MIND, NCT03342664) and for Diffusion Pharmaceuticals (PHAST-TSC, NCT03763929); serving as national principal investigator (PI) for Medtronic (Stroke AF, NCT02700945); national co-PI, late-window thrombolysis trial, NINDS (P50NS051343, MR WITNESS NCT01282242, including alteplase provided free of charge to Massachusetts General Hospital as well as supplemental per-patient payments to participating sites by Genentech); and PI, StrokeNet NINDS (New England Regional Coordinating Center, U24NS107243). No other disclosures were reported.

Figures

Figure.
Figure.. Proportions and Trends of Reperfusion Therapy for Patients With In-Hospital Stroke Onset From 2008 to 2018 in the Get With The Guidelines-Stroke National Database
A and B, Trend analysis performed with the Cochran-Armitage test; P < .001 for both metrics presented in each plot. C, Linear model fitted on quarterly intravenous thrombolysis (IVT) rates indicates a slope of 0.26 (P < .001) and an estimated annual utilization rate increase of 1.05%. D, Piecewise linear models with cutoffs at 2013 and 2015 were used to account for the publishing of the negative (2013) and subsequent positive (2015) endovascular therapy (EVT) trials. No significant increase in EVT use before 2015; estimated annual increase in EVT use after 2015 is 0.93%, with a slope of 0.23 (P < .001). Q1 indicates first quarter; and tPA, tissue plasminogen activator. aP < .001. bP = .94. cP = .40.
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References

    1. Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK. Care and outcomes of patients with in-hospital stroke. JAMA Neurol. 2015;72(7):749-755. doi:10.1001/jamaneurol.2015.0284 - DOI - PubMed
    1. Emmett ES, Douiri A, Marshall IJ, Wolfe CDA, Rudd AG, Bhalla A. A comparison of trends in stroke care and outcomes between in-hospital and community-onset stroke—the South London Stroke Register. PLoS One. 2019;14(2):e0212396. doi:10.1371/journal.pone.0212396 - DOI - PMC - PubMed
    1. Bekelis K, Missios S, Coy S, MacKenzie TA. Comparison of outcomes of patients with inpatient or outpatient onset ischemic stroke. J Neurointerv Surg. 2016;8(12):1221-1225. doi:10.1136/neurintsurg-2015-012145 - DOI - PubMed
    1. Cumbler E, Wald H, Bhatt DL, et al. . Quality of care and outcomes for in-hospital ischemic stroke: findings from the national Get With The Guidelines-Stroke. Stroke. 2014;45(1):231-238. doi:10.1161/STROKEAHA.113.003617 - DOI - PubMed
    1. Moradiya Y, Levine SR. Comparison of short-term outcomes of thrombolysis for in-hospital stroke and out-of-hospital stroke in United States. Stroke. 2013;44(7):1903-1908. doi:10.1161/STROKEAHA.113.000945 - DOI - PMC - PubMed

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