Patient refusal of thrombolytic therapy for suspected acute ischemic stroke

Reasons withholding intravenous thrombolysis for acute ischemic stroke in an Indonesian Tertiary Center

Background

Intravenous thrombolysis is the current therapy of choice in patients with acute ischemic stroke (AIS). While highly effective, the rate at which the procedure is employed is low. Studies evaluating the causes withholding thrombolytic treatment in developing nations remain scarce. We aim to determine the factors withholding thrombolytic treatment in AIS patients.

Methods

This is a retrospective study of AIS patients at Siloam Hospitals Lippo Village, Indonesia, in a 10-month period between April 2019 to February 2020. Patient data were collected from the medical records.

Results

One hundred and forty-five cases of AIS were found within a 10-month period (April 2019 to February 2020). Thrombolysis was performed in 6.90% of all patients with AIS (21.28% when adjusted for eligible patients with onset ≤ 4.5 h). Prehospital delay exceeding 4.5 h was the most common cause of withholding thrombolytic treatment (68.28% of patients present above 4.5 h or with unknown onset). Among patients presenting ≤ 4.5 h, causes withholding thrombolysis include clinical improvement (35.14%), mild non-disabling symptoms (32.43%), patient/family refusal (18.92%), extensive infarction (5.41%), seizures at onset (2.7%), as well as history of acute bleeding diathesis (2.7%) and gastrointestinal bleeding (2.7%).

Conclusions

Prehospital delay constitutes the primary obstacle toward receiving thrombolytic therapy for AIS, especially in developing countries. Among patients with onset below 4.5 h, other notable causes include clinical improvement, mild non-disabling symptoms, and patient/family refusal. Of note, the rate of patient/family refusal in our study was much higher compared to previous findings, which may reflect possible socio-economic, communication, or educational issues.

Sex and Gender Differences in Stroke and Their Practical Implications in Acute Care

There are several controversies regarding the role of sex and gender in the pathophysiology and management of acute stroke. Assessing the role of sex, i.e., biological/pathophysiological factors, and gender, i.e., sociocultural factors, in isolation is often not possible since they are closely intertwined with each other. To complicate matters even more, the functional baseline status of women and men at the time of their first stroke is substantially different, whereby women have, on average, a poorer reported/ascertained baseline function compared to men. These differences in baseline variables account for a large part of the differences in post-stroke outcomes between women and men. Adjusting for these baseline differences is difficult, and in many cases, residual confounding cannot be excluded. Despite these obstacles, a better understanding of how patient sex and gender differences influence acute stroke and stroke care pathways is crucial to avoid biases and allow us to provide the best possible care for all acute stroke patients. Disregarding patient sex and gender on one hand and ignoring potential confounding factors in sex- and gender-stratified analyses on the other hand, may cause researchers to come to erroneous conclusions and physicians to provide suboptimal care. This review outlines sex- and gender-related factors in key aspects of acute stroke, including acute stroke epidemiology, diagnosis, access to care, treatment outcomes, and post-acute care. We also attempt to outline knowledge gaps, which deserve to be studied in further detail, and practical implications for physicians treating acute stroke patients in their daily practice.

Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke

BACKGROUND

Prior regional or single-center studies have noted that 4-7% of eligible acute ischemic stroke (AIS) patients decline intravenous tissue plasminogen activator (tPA). We sought to determine the prevalence of tPA declination in a nationwide registry of AIS patients and to investigate differences in declination by race-ethnicity.

METHODS

We used the Get With The Guidelines-Stroke registry to identify AIS patients eligible for tPA and admitted to participating hospitals between January 1, 2016 and March 28, 2019. We compared patient demographics and admitting hospital characteristics between tPA-eligible patients who received and those who declined tPA. Using multivariable logistic regression, we determined patient and hospital factors associated with tPA declination.

RESULTS

Among 177,115 tPA-eligible acute ischemic stroke patients at 1,976 sites, 6,545 patients (3.7%) had tPA declination as the sole documented reason for not receiving tPA. Patients declining treatment were slightly older, more likely to be female, arrived more often at "off-hours" and earlier after symptom onset, and were more likely to present to primary stroke centers. Compared with non-Hispanic White, non-Hispanic Black race-ethnicity was independently associated with increased (aOR 1.21, 95% CI 1.11-1.31), Asian race-ethnicity with decreased (aOR 0.72, 95% CI 0.58-0.88), and Hispanic ethnicity (any race) with similar odds of tPA declination (OR 0.98, 95% CI 0.86-1.13) in multivariable analysis.

CONCLUSIONS

Though the overall prevalence of tPA declination is low, eligible non-Hispanic Black patients are more likely and Asian patients less likely to decline tPA than non-Hispanic White patients. Reducing rates of tPA declinations among non-Hispanic Black patients may be an opportunity to address disparities in stroke care.

Thrombolytic Refusal Over Telestroke

Background

Tissue plasminogen activator (tPA) refusal is 4%-6% for acute ischemic stroke (AIS) in the emergency department. Telestroke (TS) has increased the use of tPA for AIS but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.

Methods

Patients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.

Results

Among the 1,242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic Black patients and patients with a prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and were associated with a final diagnosis of stroke mimic (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.15-0.36). Good outcome (90-day modified Rankin Scale 0-2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42-1.54). The most common reasons for refusal were rapidly improving and mild/nondisabling symptoms and concern for potential side effects.

Conclusion

tPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared with those who refused. Sex and racial differences associated with an increased tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.

Improving timely treatment with a stroke emergency map: The case of northern China

OBJECTIVE

The Chinese stroke emergency map (SEM) was implemented in 2017 to reduce prehospital and hospital delays for acute ischemic stroke (AIS) patients suitable for intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis. However, data on the time delay following the implementation of an SEM in China are limited.

METHODS

Data for suspected stroke patients from the SEM registry center of Taiyuan, Shanxi Province, from August 2017 to July 2019, patients' characteristics, thrombolysis rate, and functional outcome at 90 days were analyzed.

RESULTS

One thousand seven hundred and eighty six patients who arrived at hospitals within 4.5 hr of onset were included; 35.9% arrived by emergency medical services (EMSs), and 1,207 (67.6%) of the population received intravenous rt-PA. As a result of the SEM, the number of patients treated with rt-PA increased from 63.9% in phase 1 (August 2017 to July 2018) to 70.5% in phase 2 (August 2018 to July 2019). The median onset-to-door and onset-to-needle times decreased by five minutes (100 [IQR: 62-135] vs. 105 [IQR: 70-145], p = .005) and nine minutes (158 [IQR: 124-197] vs. 167 [IQR: 132-214], p = .001), respectively. Patients in phase 2 achieved greater independent function outcome at 90 days (79.9% vs. 72.1%; adjusted odds ratio, 2.010; 95% confidence interval, 1.444-2.798). The binary logistic regression models revealed that shorter onset-to-needle time (OR: 0.994; 95% CI: 0.992-0.997; p < .001) and lower baseline NIHSS scores (OR: 39.120; 95% CI: 23.477-65.188; p < .001 and OR: 18.324; 95% CI: 11.425-29.388; p < .001 and OR: 3.123; 95% CI: 2.044-4.773; p < .001) were significant predictors for the independent function outcome.

CONCLUSION

The implementation of a stroke emergency map is more likely to reduce prehospital delays and improve function outcomes. Future efforts should attempt to increase EMS usage.

Sex differences in IV thrombolysis treatment for acute ischemic stroke

Objective

A prior meta-analysis of reports published between 2000 and 2008 found that women were 30% less likely to receive IV recombinant tissue plasminogen activator (rtPA) treatment for stroke than men; we updated this meta-analysis to determine if this sex difference persisted.

Methods

We identified studies that reported sex-specific IV rtPA treatment rates for acute ischemic stroke published between 2008 and 2018. Eligible studies included representative populations of patients with ischemic stroke from hospital-based, registry-based, or administrative data. Random effects odds ratios (ORs) were generated to quantify sex differences.

Results

Twenty-four eligible studies were identified during this 10-year period. The summary unadjusted OR based on 17 studies with data on all ischemic stroke patients was 0.87 (95% confidence interval [CI], 0.82–0.93), indicating that women had 13% lower odds of receiving IV rtPA treatment than men. However, substantial between-study variability existed. Lower treatment odds in women were also observed in 7 studies that provided data on the subgroup of patients eligible for IV rtPA treatment, although the summary OR of 0.95 (95% CI, 0.88–1.02) was not statistically significant. Examination of time trends across 33 studies published between 2000 and 2018 found evidence that the sex difference had narrowed in more recent years.

Conclusions

Although there is considerable variability in the findings of individual studies, pooled data from recent studies show that women with acute stroke are less likely to be treated with IV thrombolysis compared with men. However, the size of this difference has narrowed compared to studies published before 2008.

Legal medicine implications in fibrinolytic therapy of acute ischemic stroke

Background

Before the advent of fibrinolytic therapy as a gold standard method of care for cases of acute ischemic stroke in Romania, issues regarding legal medicine aspects involved in this area of medical expertise were already presented and, in the majority of cases, the doctors seem to be unprepared for these situations.

Main text

The present research illustrates some of the cases in which these aspects were involved, that adressed a clinical center having 6 years of professional experience in the application of fibrinolytic treatment for stroke. The following cases report either situations in which the afore mentioned therapy was not rightfully administrated or legal aspects regarding the obtainment of informed consent.

Conclusion

Obtaining informed consent is a mandatory procedure, which takes time, to the detriment of application of fibrinolytic treatment.

Racial disparities in refusal of stroke thrombolysis in Chicago

OBJECTIVE

To evaluate race differences in tissue plasminogen activator (tPA) refusal among eligible patients with acute ischemic stroke (AIS) in Chicago.

METHODS

Using the Get With The Guidelines-Stroke registry data from 15 primary stroke centers between January 2013 and June 2015, we performed a retrospective analysis of patients with AIS presenting to the emergency department within 4.5 hours from symptom onset. Patient or proxy refusal was captured as a reason for nonadministration of tPA to eligible patients in the registry. We assessed whether tPA refusal differed by race using logistic regression.

RESULTS

Among 704 tPA-eligible patients with AIS, tPA was administered to 86.2% (black race, 82.5% vs nonblack race, 89.5%; p < 0.001). Fifty-three (7.5%) tPA refusals were documented. Refusal was more common in black vs nonblack patients (10.6% vs 4.8%; p = 0.004). In multivariable analysis, the following were associated with tPA refusal: black race (adjusted odds ratio [OR] 2.5, 95% confidence interval [CI] 1.3-4.6), self-pay status (adjusted OR 3.23, 95% CI 1.2-8.71), prior stroke (adjusted OR 2.11, 95% CI 1.14-3.90), age (adjusted OR 1.04, 95% CI 1.02-1.07), and NIH Stroke Scale score (adjusted OR 0.94, 95% CI 0.90-0.99).

CONCLUSIONS

Among tPA-eligible patients with AIS in Chicago, over 7% refused tPA. Refusal was more common in black patients and accounted for the apparent lower rates of tPA use in black vs nonblack patients. Further research is needed to understand barriers to consent and overcome race-ethnic disparities in tPA treatment for AIS.

Advance preferences regarding thrombolysis in patients at risk for stroke: a cross-sectional study

BACKGROUND

It is difficult to obtain informed consent for thrombolysis in stroke patients given the emergency setting, the need for a speedy decision and the effects of neurological deficits.

AIM

To determine the advance preferences for thrombolysis of patients at risk for stroke following discussion of the potential risks and benefits.

DESIGN

Cross-sectional survey.

METHODS

Data on benefits and risks of thrombolysis within 3 h and between 3 and 4.5 h after stroke were presented orally, in writing and pictorially to patients attending geriatric and stroke services in a teaching hospital with specified stroke risk factors and preferences for thrombolysis were recorded.

RESULTS

Of the 121 participants, 108 (89.3%; 95% confidence interval [CI] 82.4-93.7) would opt for thrombolysis within the 3-h period and 100 (82.6%; 95% CI 74.9-88.4) within the 3- to 4.5-h period after acute stroke (P = 0.04, McNemar's test for correlated proportions). Previous stroke or transient ischaemic attack was more common among those who agreed to thrombolysis (54.1% vs. 30.4%, P = 0.04) and those who opted for thrombolysis were significantly more likely to agree to have their preferences recorded and used in the event of a stroke than those who refused thrombolysis (88.8% vs. 30.4%, P = 0.002).

CONCLUSION

Advance discussion of the potential risks and benefits of thrombolysis in at-risk patients may improve decision making if thrombolysis is being considered and the patient can no longer make a decision.