Use Of Intravenous Thrombolytic Therapy Research Articles

A Nursing Approach to Improving Critical Care Compliance With Vital Signs and Neurological Assessments in Post-IV-Alteplase Stroke Patients

Ischemic stroke represents 87% of all strokes. As global initiatives move forward with stroke care, health care providers and institutions will be called on to deliver the most current evidence-based care. The American Heart Association/American Stroke Association (AHA/ASA) estimates that 795 000 strokes occur each year; 610 000 are new strokes, and 185 000 are recurrent strokes. Eighty-seven percent are ischemic strokes; the overall mortality rate from stroke was 273 000, which makes stroke the fifth leading cause of death and the leading cause of disability in the United States. Stroke costs the United States an estimated $34 billion each year. This article outlines a nursing intervention regarding the use of intravenous thrombolytic therapy for treating acute ischemic stroke, the risk factors related to IV-alteplase, best-practice protocols, and the nursing role in efforts to deliver safe care. The conclusion reveals the need for health care organizations to explore opportunities, continually inspire innovation at the bedside, highlight nursing's essential contribution to acute stroke care, and encourage publishing improvements in patient care and the nurse practice environment.

Abstract 3: Increasing Use of Intravenous Thrombolytic Therapy was Associated With Decline in Ischemic Stroke Mortality in Medicare Beneficiaries

Background: Mortality due to stroke has declined over the past 2 decades. Intravenous thrombolytic therapy improves the functional outcome, but its contribution in reducing stroke mortality is not clear. We aim to examine the trend of ischemic stroke case fatality in recent years in relation to the utilization of thrombolytic therapy. Methods: We examined the trend of risk-adjusted one-year mortality and intravenous thrombolytic therapy in Medicare beneficiaries aged ≥65 years who were hospitalized between January 1, 2009 and December 31, 2013 with a primary discharge diagnosis of acute ischemic stroke. The data of the patient information were obtained from the Medicare Provider Analysis and Review file. Cox proportional hazards models were generated to adjust for patient demographics and comorbidities. All statistical analyses were performed using SAS Version 9.4 software. Results: This study included 1,165,960 Medicare Beneficiaries. The one-year risk-adjusted mortality showed a steady declined from 29.7% in 2009 to 24.4% in 2013, 17.8% decline over the five year period. This was parallel to the 59.7% increase of intravenous thrombolytic therapy utilization, from 5.21% in 2009 to 8.32% in 2013. The mortality decline was only observed in patients who received intravenous thrombolytic therapy (HR 0.86; 95% CI 0.82-0.91), but not in those who did not receive thrombolytic therapy (HR 0.99; 95% CI 0.97-1.01) (Table). Conclusion: The increasing use of intravenous thrombolytic therapy was associated with decline in risk-adjusted one-year mortality after ischemic stroke. The reasons for the mortality decline among those who received thrombolytic therapy needs further explanation.

Abstract TP305: International Comparison of Patient Characteristics and Performance Measures in Acute Ischemic Stroke: Analysis of the American Heart Association Get With the Guidelines-Stroke Registry and China National Stroke Registry

Background: Stroke is a key contributor to the global burden of disease and the second leading cause of death worldwide. Efforts to measure and improve care are rapidly extending to low and middle income countries. Yet there is lack of comparative assessment of characteristics and adherence to evidence-based performance measures in acute ischemic stroke for most world regions. Methods: We analyzed data of consecutive acute ischemic stroke patients in the Get With The Guidelines Stroke (n=194,876 from 1548 sites) and the China National Stroke Registry (n=19,604 from 217 sites) between 2012 and 2013. Patient characteristics and adherence to guideline-based performance measure in both countries were compared. Results: Compared with their US counterparts, Chinese patients were much younger (mean 64.8 vs. 70.5 years), had lower prevalence of comorbidities except for prior stroke/TIA and smoking, had less severe stroke (NIHSS, mean 5.4 vs. 6.8) and more delay from symptom onset to arrival (median 22 vs. 11 hours) (all p<.001). Overall, use of intravenous thrombolytic therapy was 2.4% in China (tPA 1.4% and urokinase 1.0%) and 8.1% in US (tPA). Chinese compared with US patients experienced more treatment delay (door-to-needle time, median 95 vs. 62 minutes, p<.001). Adherence to early and discharge antithrombotics, smoking cessation counseling, and dysphagia screening were fairly high in China (>80%), although numerically lower than in the US. The largest differences between performance measure adherence in Chinese and US care were seen in timeliness of tPA treatment, venous thromboembolism prophylaxis, lipid lowering therapy, anticoagulation for atrial fibrillation, and rehabilitation assessment (Figure). Conclusion: We found important differences in clinical characteristics and gaps in adherence to certain performance measures between China and the US. National efforts are needed for continued improvements in acute ischemic stroke care in both countries.

Abstract TMP63: Region-wide, Prehospital Mobile Tele-Evaluation by a Central Neurologist Reduces Disparities in Lytic Therapy for Acute Stroke

Background: Disparities in the delivery of acute stroke care among diverse race-ethnic populations have been well documented, including lower rates of use of intravenous thrombolytic therapy and longer door to needle times. We sought to determine if prehospital mobile telemedical patient evaluation by a neurologist responding to all stroke ambulance transports in a region would reduce these disparities. Methods: Subjects were participants in the Phase 3 NIH Field Administration of Stroke Therapy - Magnesium (FAST-MAG) trial of prehospital magnesium vs. placebo within 2 hours from symptom onset. A central neurologist performed mobile prehospital tele-evaluation, using audio or video smartphones, of all study candidate patients being transported by 315 ambulances to 60 hospitals throughout Los Angeles and Orange County. After confirming likely stroke and eliciting informed consent, the neurologist spoke to the attending ED physician in the destination hospital and gave pre-arrival report. Results: Of 1700 subjects, race-ethnic distribution included: white, non-Hispanic - 929 (55%): white, Hispanic - 402 (24%); black - 219 (13%); and Asian - 139 (8%).. Among the 1245 (73%) patients with a final diagnosis of acute cerebral ischemia (ACI), 444 (36%) were treated with IV tPA. In all ACI patients, the median time from door to imaging was 28 minutes (IQR 19-42). In the tPA-treated patients, median door to imaging time was 25 mins (18-35) and door to needle time 79 mins (62-104);. There were no differences in rates of tPA utilization among non-Hispanic Whites (35%), Blacks (35%) and Latinos (35%) with cerebral ischemia. There were also no significant differences in door to imaging (24 vs. 28 vs. 25 minutes, p=0.39 or door to needle (83 vs. 77 vs. 78 minutes, p=0.57) Conclusions: Central neurologist mobile tele-evaluation of potential stroke patients transported by all ambulances throughout a region with 13.1 million persons is feasible, and is associated with resolution of disparities in use and speed of thrombolytic therapy for acute ischemic stroke.

Use of Intravenous Thrombolytic Therapy in Acute Ischemic Stroke Patients: Evaluation of Clinical Outcomes.

The use of intravenous thrombolytic therapy (ITT) in acute ischemic stroke (AIS) patients is still debated in China. We present the analysis of clinico-demographic retrospective data of 646 AIS patients that were treated by alteplase ITT at our hospital. The data collected included age, gender, education, income, drug use before disease onset, and awareness of stroke/ITT. The risk factors studied were hypertension, diabetes, hyperlipidemia, atrial fibrillation, coronary heart disease, cerebral infarction, transient ischemic attack, valvular heart disease, thyroid disease, migraine, asymptomatic carotid stenosis, family history of stroke, hyperhomocysteinemia, smoking, drinking, and gingivitis. Pre-ITT patient data included blood pressure and time from onset to hospital. Post-ITT patient data included National Institutes of Health Stroke Scale (NIHSS) scores, clinical outcome, revascularization, hemorrhage, healing rate, and 90-day mortality. Hospital management information included monthly ITT cases, discharges, bed turnaround times, length of hospital stay, bed utilization, drug ratio, massive cerebral infarction decompressive craniectomy, and social impact. Prognosis evaluation was based on post-ITT NIHSS and modified Rankin Scale (mRS) scores. We found that ITT success rate was 75.85 %, with a bleeding rate of 1.55 % and a 90-day mortality rate of 2.01 %. Overall, the data suggest that the ITT therapy was highly successful in AIS patients treated at our hospital.

A male Fabry disease patient treated with intravenous thrombolysis for acute ischemic stroke

The use of intravenous thrombolytic therapy for acute ischemic stroke is associated with improved outcomes. Fabry disease is an X-linked glycosphingolipid storage disease with vascular endothelial deposits. Affected males with the classic phenotype develop renal, cardiac, and cerebrovascular disease and die prematurely. However, Fabry disease is rare in young men with first ischemic stroke of undetermined cause. We report a 38-year-old man with acute aphasia and a left M2 segment of the middle cerebral artery thrombus with no recanalization who was finally diagnosed with Fabry disease after left ventricular hypertrophy of undetermined cause had been identified. A gene test revealed a R227X mutation typical of Fabry disease with the classical phenotype. To our knowledge our patient is the first reported male Fabry patient who was given intravenous thrombolytic therapy and the first reported Fabry patient who received intravenous thrombolytic therapy between 3 and 4.5hours of the symptom onset. Despite favorable prognostic indicators on admission imaging, our patient suffered a significant stroke and had an unfavorable clinical outcome. Fortunately, the episode was not complicated by intracranial hemorrhage. Further studies are needed to evaluate the efficacy and safety of intravenous thrombolytic therapy in treating patients with Fabry disease and acute ischemic stroke.

Thrombolysis in acute ischaemic stroke: Initial experience in a general hospital in a developing country

Background: The aim of the study was to present our initial experience with the use of intravenous thrombolytic therapy in patients with acute ischaemic stroke. We present results related to demography, time, and/INS; data on the clinical outcome of patients and compare the results with other studies (Serbian Experience with Thrombolysis in Ischemic Stroke (SETIS) and Safe Implementation of Treatments in Stroke (SITS)).

Intravenous Thrombolysis for Acute Ischemic Stroke

Marc Fisher MD Kennedy Lees MD Section Editors: On September 26, 2008, the New England Journal of Medicine published the results of the European Cooperative Stroke Study (ECASS) III,1 the first randomized, placebo-controlled trial to demonstrate safe and effective use of intravenous recombinant tissue plasminogen activator (rtPA) to treat patients with acute ischemic stroke (AIS) beyond 3 hours from stroke onset. The ECASS investigators studied the safety and efficacy of administering intravenous rtPA to patients with AIS 3 to 4.5 hours after AIS onset. Using the modified Rankin Scale score at 90 days after stroke occurrence as the primary end point of the study, the investigators demonstrated a modest, statistically significant increase in the likelihood of having normal or near normal recovery (modified Rankin Scale=0 or 1) in favor of rtPA treatment compared with placebo (unadjusted OR, 1.34; 95% CI, 1.02 to 1.76; P =0.04). So, what impact will the results of the study have on acute stroke management and stroke research in the United States and elsewhere? With regard to the first part of the question, the answer is complex. First, the ECASS III results will hopefully help to increase the number of thrombolysis eligible patients with AIS who receive rtPA. Twelve years after the US Food and Drug Administration approved the management of AIS within 3 hours of symptom onset as an indication for the use of intravenous rtPA, less than 5% of patients with AIS are being treated worldwide with rtPA within 3 hours of stroke onset. One of the major factors contributing to this parlous state of affairs has been disagreement among healthcare professionals about the validity of the results of the National Institutes of Neurological Disorders and Stroke (NINDS) trial of rtPA for acute stroke.2 In the late 1990s, the stroke community unexpectedly …

EPITHET—where next?

The Echoplanar Imaging of Thrombolytic Evaluation Trial (EPITHET) investigators should be highly commended for their randomised, placebo-controlled trial, which provides much needed objective evidence on the use of mismatch in perfusion and diffusion-weighted MRI as a surrogate measure for the extent of the ischaemic penumbra.1 We agree with the investigators that these results should not be taken as a mandate for wider use of mismatch to select patients for use of intravenous thrombolytic therapy with alteplase off-label (ie, beyond 3 h).

Selection of thrombolytic therapy beyond 3 h using magnetic resonance imaging

Use of intravenous thrombolytic therapy in ischaemic stroke is restricted to a 3-h time window because of the proof of this time window in pivotal clinical trials. Thrombolysis is aimed at recanalization of occluded arteries and reperfusion of the ischaemic penumbra, a region of critically hypoperfused, functionally impaired, but potentially viable brain. There are a number of current prospective trials that are testing the hypothesis that the presence of the penumbra will predict thrombolytic responders beyond 3 h. Using magnetic resonance imaging, a mismatch between a larger perfusion-weighted imaging lesion and smaller diffusion-weighted imaging lesion is considered to represent the ischaemic penumbra. Perfusion-weighted imaging provides semiquantitative cerebral blood flow imaging and diffusion-weighted imaging is an index of the largely irreversible ischaemic core. This definition has been modified with the recognition that the perfusion-weighted imaging lesion includes benign oligaemia and that a portion of the diffusion-weighted imaging core is potentially salvageable with rapid reperfusion. Most acute stroke patients have a magnetic resonance imaging-penumbral signature within 6 h of stroke onset. The penumbra is commonly, but not invariably, associated with proximal arterial occlusion and is time-dependent. Preliminary studies have shown benefit from thrombolytic therapy beyond the established 3-h window. Penumbral imaging using magnetic resonance imaging with perfusion over diffusion weighted imaging mismatch can provide a physiological 'tissue clock' in individual patients. Based on this hypothesis, a number of prospective trials are being performed. These include EPITHET, DEFUSE, DIAS, MR RESCUE and ROSIE.

Thrombolytic Therapy in Acute Ischemic Stroke.

The use of intravenous thrombolytic therapy for the treatment of patients with acute ischemic stroke is now approved in the United States, Canada, Germany, and the European Union. Guidelines published in 1996 from the American Heart Association and American Academy of Neurology committees recommended intravenous administration of recombinant tissue-plasminogen activator (rt-PA) (0.9 mg/kg; maximum of 90 mg) given in a 10% bolus, followed by an infusion lasting 60 minutes, to patients within 3 hours of onset of ischemic stroke. The recommendations stipulate that a computed tomography scan before the infusion should not show major infarction, mass effect, edema, or hemorrhage. Yet, only a small fraction of eligible patients (< 5%) have received rt-PA during the 7 years since its approval in the United States. Although effective, thrombolysis carries an important risk (5% to 10%) of brain hemorrhage and edema that can prove fatal. Many physicians and medical centers are not presently equipped or willing to give thrombolytic drugs for stroke treatment.

Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the U.S. from 1990 through 1999: The National Registry of Myocardial Infarction 1, 2 and 3

OBJECTIVESWe sought to determine trends in the treatment of myocardial infarction from 1990 through 1999 in the U.S. and to relate these trends to current guidelines.BACKGROUNDLimited data are available to show how recent clinical trials and clinical guidelines have impacted treatment of myocardial infarction.METHODSTemporal trends in myocardial infarction treatment and outcome were assessed by using data from 1,514,292 patients in the National Registry of Myocardial Infarction (NRMI) 1, 2 and 3 from 1990 through 1999.ResultsDuring this interval, the use of intravenous thrombolytic therapy declined from 34.3% to 20.8%, but the use of primary angioplasty increased from 2.4% to 7.3% (both p = 0.0001). The median “door-to-drug” time among thrombolytic therapy recipients fell from 61.8 to 37.8 min (p = 0.0001), primarily owing to shorter “door-to-data” and “data-to-decision” times. The prevalence of non–Q wave infarctions increased from 45% in 1994 to 63% in 1999 (p = 0.0001). From 1994 through 1999, there was increased usage of beta-blockers, aspirin and angiotensin-converting inhibitors, both during the first 24 h after admission and on hospital discharge (all p = 0.0001). Between 1990 and 1999, the median duration of hospital stay fell from 8.3 to 4.3 days, and hospital mortality declined from 11.2% to 9.4% (both p = 0.0001).CONCLUSIONSThe NRMI data from 1990 through 1999 demonstrate that the recommendations of recent clinical trials and published guidelines are being implemented, resulting in more rapid administration of intravenous thrombolytic therapy, increasing use of primary angioplasty and more frequent use of adjunctive therapies known to reduce mortality, and may be contributing to the higher prevalence of non–Q wave infarctions, shorter hospital stays and lower hospital mortality.

Simultaneous bilateral thalamic hemorrhages following the administration of intravenous tissue plasminogen activator

A patient suffered the onset of simultaneous bilateral thalamic hemorrhage several hours after the administration of intravenous tissue plasminogen activator. The patient exhibited features of the paramedian diencephalic syndrome, including executive dysfunction, anterograde amnesia, inattention, and disturbances of visual perception. During rehabilitation, she made significant gains in overlearned activities of daily living tasks, but her inability to retain new information left her severely disabled. The use of intravenous thrombolytic therapy is believed to account for this patient's unusual stroke syndrome. With recent evidence supporting the efficacy of intravenous thrombolysis in acute stroke, patients with multiple hemorrhagic strokes as a result of thrombolysis may become more common on rehabilitation services.

Immediate coronary angioplasty versus intravenous streptokinase in acute myocardial infarction: Left ventricular ejection fraction, hospital mortality and reinfarction

Objectives. The purpose of the present study was to compare intravenous Streptokinase therapy with immediate coronary angioplasty without antecedent thrombolytic therapy with regard to left ventricular function and hospital mortality and reinfarction.Background. Despite the widespread use of intravenous thrombolytic therapy and immediate percutaneous transluminal coronary angioplasty, these two strategies to treat patients with an acute myocardial infarction have only recently been compared in randomized trials. Coronary angioplasty has been shown to result In a higher patency rate of the Infant-related coronary artery, with a less severe residual stenotic lesion, compared with streptokinase therapy, but whether this more favorable coronary anatomy results in clinical benefit remair to be established.Methods. We studied 301 patients with acute myocardial infarction randomly assigned to undergo immediate coronary angioplasty without antecedent thrombolytic therapy or to receive intravenous streptokinase therapy. Before discharge left ventricular ejection fraction was measured by radionuclide scanning.Results. The in-hospital mortality rate in the streptokinase group was 7% (11 of 149 patients) compared with 2% (3 of 152 patients) in the angioplasty group (p = 0.024). In the streptokinase group recurrent myocardial infarction occurred in 15 patients (10%) versus in 2 (1%) in the angioplasty group (p < 0.001). Either death or nonfatal reinfarction occurred in 23 patients (15%) in the streptokinase group and in 5 patients (3%) in the angioplasty group (p = 0.001). Left ventricular ejection fraction was 44 ± 11% (mean ± SD) in the streptokinase group versus 50 ± 11% in the angioplasty group (p < 0.001).Conclusions. These findings indicate that immediate coronary angioplasty without antecedent thrombolytic therapy results in better left ventricular function and lower risk of death and recurrent myocardial infarction than treatment with intravenous streptokinase.

Ratio of ST-Segment and myoglobin slopes to estimate myocardial salvage during thrombolytic therapy for acute myocardial infarction

The use of intravenous thrombolytic therapy to achieve myocardial salvage has become common practice in patients presenting during the early hours of acute myocardial infarction (AMI). 1–3 A prompt, noninvasive estimation of salvage would be useful in determining further therapy for each patient. Clinical indexes of salvage should be accurate, easy to perform, inexpensive, and yield rapid results. Standard electrocardiographic and serum biochemical methods have been shown to indicate myocardial reperfusion. 4–9 Electrocardiographic ST-segment elevation tends to partially resolve immediately after reperfusion, but only 50% of patients have as much as 50% resolution within 90 minutes. 4 Plasma levels of intracellular macromolecules increase early owing to washout through the lymph and blood, but only if irreversible damage has already occurred. 5–9 The present study of patients with AMI was designed to observe serial changes in both the ST segments, and serum levels of creatine kinase-MB and myoglobin after angiographically documented reperfusion; it tests the hypothesis that the ratio of ST-segment decrease to serum macromolecular increase can predict salvage of the jeopardized myocardium.

Acute Myocardial infarction: Treatment with Thrombolytic Therapy

The past 5 years have witnessed an explosion in the amount of published clinical trial data for the use of intravenous thrombolytic therapy for acute myocardial infarction. This article reviews the properties of the various agents, the experiences of each in prospective, randomized clinical trials, and the future directions of thrombolytic intervention.

Management of myocardial infarction shock: Current status

Major advances have occurred over the last two decades in the management of myocardial infarction shock, increasing the overall in-hospital survival rate from approximately 15% to more than 50% at the present time with aggressive methods of interventional cardiology. The widespread use of intravenous thrombolytic therapy during the early hours of myocardial infarction has resulted in a decreasing incidence of shock with first myocardial infarctions. Three mechanisms bring about cardiogenic shock: (1) extensive aggregate systolic left ventricular dysfunction, (2) extensive right ventricular infarction, and (3) mechanical defects of the left and/or right ventricles attendant to ischemic dysfunction or rupture. To permit survival in cardiogenic shock, even with maximally aggressive therapy, diagnostic evaluation must be carried out concurrently with clinical stabilization of the patient. IABC is the mainstay for supporting the patient in shock during further efforts at diagnosis and definitive therapy. Definitive therapy for cardiogenic shock may include percutaneous transluminal coronary angioplasty, emergent bypass surgery, or repair of a mechanical defect. This report details the current status of knowledge with respect to pathogenesis, recognition, and definitive treatment of myocardial infarction shock.