Patient Response Time Crucial in Stroke "Chain of Survival"

Journal Watch. 2005;4(6) 

To explore factors that affect the number of patients with acute ischemic stroke who are treated with thrombolytic therapy, the California Acute Stroke Pilot Registry (CASPR) investigators prospectively examined times from symptom onset to each point in the stroke "chain of survival" for all patients admitted to 11 California hospitals with suspected stroke or TIA over a 3-month period. They calculated how much treatment rates would have improved if each response time had been optimal, or if treatment were possible out to 6 hours.

Among the 374 patients who had an ischemic stroke diagnosed in the ED, 4.3% received tPA within 3 hours of stroke onset. Treatment rates could have increased to 28.6% if all patients had called 911 immediately, to 5.7% if transport time was instantaneous, and to 11.5% if all eligible patients who arrived in the ED within 3 hours were treated. If all three response times were optimized, a striking 57% of patients could have been treated. Using a drug effective up to 6 hours after stroke onset, if one were available, would have increased treatment rates to only 8.3%. The authors conclude that educating all patients or observers to recognize stroke onset and call 911 immediately would have the greatest impact on ischemic stroke treatment rates.

The overall message of this study is that it should be possible to increase stroke-treatment rates beyond the current dismal 2% to 4%. Most stroke centers have first addressed ED care, as emphasized by the NINDS Stroke Study Group (Stroke 1997; 28:1530). After all, what is the point of getting more eligible patients to the ED if we are not prepared to treat them? This logical first step has apparently been about 33% successful in California. Perfect ED care would have almost tripled the treatment rate in this study. Paramedic response, particularly stroke recognition and preferential triage to appropriate facilities, can also be very effective (Wojner AW et al. Stroke; in press). Notably, the estimated doubling of the treatment rate with a hypothetical treatment effective up to 6 hours after onset, although important, is probably lower than that assumed by pharmaceutical companies.

Most important, the findings show that improving patient response would have the greatest effect by far (a six- to sevenfold treatment-rate increase). Community education is costly and not necessarily effective, as shown by response times to chest pain in the REACT trial (JAMA 2000; 284:60). However, Morgenstern and colleagues showed that a targeted community-wide message of empowerment and role modeling, coupled with ED and paramedic education, increased stroke treatment rates fivefold (Stroke 2002; 33:160 and Arch Intern Med 2003; 163:2198). As in REACT, the number of patients arriving within 3 hours was not appreciably increased, but a greater percentage of these patients got treated. Clearly, however, we still don't know how to communicate the message well. Cost, language, and ethnocultural barriers may need to be addressed. Finally, Morgenstern found that co-workers and family members, not stroke patients themselves, usually call 911. This implies that we should target general community education at the workplace and in schools — a hypothesis that my colleagues and I are testing (Stroke 2005; 36:42 [abstract]).

— James C. Grotta, MD

Dr. Grotta is Professor of Neurology and Director of Vascular Neurology, University of Texas Houston Medical School.

Johnston SC et al. for the California Acute Stroke Pilot Registry (CASPR) Investigators. Prioritizing interventions to improve rates of thrombolysis for ischemic stroke. Neurology 2005 Feb 22; 64:654-9.

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