Academic journal article Australian Health Review

Thrombolysis in Acute Stroke: Ongoing Challenges Based on a Tertiary Hospital Audit and Comparisons with Other Australian Studies

Academic journal article Australian Health Review

Thrombolysis in Acute Stroke: Ongoing Challenges Based on a Tertiary Hospital Audit and Comparisons with Other Australian Studies

Article excerpt

Introduction

Acute stroke is the third most common cause of disability and death in Australia.1 Intravenous tissue plasminogen activator (tPA) has been increasingly used since the National Institute of Neurological Disorder and Stroke (NINDS) trial in 1995 demonstrated complete or near-complete resolution of stroke symptoms in 39% of patients receiving tPA compared with 26% in the placebo group.2 The benefit of tPA has been confirmed by Cochrane review and meta-analyses.3-5 Phase IV studies and data from a large registry (Safe Implementation of Thrombolysis in Stroke (SITS))6-8 have shown tPA to be as safe and effective when administered in routine clinical practice as it is in major trials.

Intravenous tPA was licensed in Australia for the treatment of acute ischaemic stroke in August 2003. In 2008, the results of the third European Cooperative Acute Stroke Study (ECASS III) extended the time window for tPA administration from 3.0 to 4.5 h.9 In 2009-10, the National Stroke Foundation and Stroke Society of Australasia recommended that tPA be administered to all eligible patients with acute ischaemic stroke.10,11 Thrombolysis has been increasingly adopted in stroke units throughout different states12-15 and a recent SITS report showed the delivery, outcome and safety of tPA in Australia to be comparable with that in other countries.16 However, although 49% of patients arrive in hospital within 3 h and 58% within 4.5 h of stroke onset,17 the rate of thrombolysis varies from as low as 7%17 to 21%.16 Lower rates are likely due to initial diagnostic uncertainty, strict eligibility criteria, limited time window for safe administration and the requirement for stroke units to oversee the safe care of patients receiving tPA. The proportion of Australian hospitals with established strokeunits, basedonsurveys, has increasedfrom21% (54/ 257) in 2007,18 to 39% (74/188) in 2011 and to 52% (92/177) in 2013, with Queensland (Qld) showing the highest uptake rate.19 However, such units only admit 58% of all stroke patients, indicating problems with access.19

Aims

To our knowledge, no Qld hospital has published its results for thrombolysis in acute ischaemic stroke. Because clinical practice and patient outcomes can vary geographically and according to different models of care, it is important to report thrombolysis activity and outcome data from different centres in a standardised format in determining the most suitable service configuration. Theaims of the present study were to:(1) profile the first 3years of experienceofadministeringtPA inacuteischaemicstrokeata Qld tertiary hospital since its inception of thrombolysis in early 2010; and (2) compare results with those published in other Australian studies.

Methods

Settings and patients

Princess Alexandra Hospital (PAH) is a 700-bed tertiary hospital in Brisbane (Qld, Australia). It has a six-bed acute stroke unit and a stroke team comprising physicians trained in general medicine, neurology and geriatric medicine with interest in stroke medicine and extensive experience in managing stroke patients, junior medical staff and specialised nurses. The unit liaises closely with the emergency department (ED) and neuroradiology. In January 2010, the PAH started administering intravenous tPA for acute ischaemic stroke within 4.5 h of symptom onset, using a standardised protocol (Fig. 1) and treatment eligibility checklist (available on request from the authors), overseen by a stroke physician on a 24/7 roster. All stroke patients who received intravenous tPA from 1 January 2010 to 31 December 2012 were included in the present study.

Data collection

The present retrospective study identified all eligible patients from a prospectively maintained thrombolysis database that records all patients who have received thrombolysis since 2010. The unit keeps a separate registry for all other admissions to the acute stroke unit. Additional patient data were extracted from medical charts and entered into a thrombolysis database. …

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