Stroke: Patients who present in 'golden hour' still don't reach proper DTN times

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While a majority of ischemic stroke patients arrive during the "golden hour"—60 minutes of less after the onset of symptoms—still those who arrive earlier get treated slower than those who arrive later, proving that more educational programs to make the public aware of stroke symptoms and the importance of early arrival to the emergency department (ED) are needed, according to a study published online June 3 in Stroke.

“The benefit of intravenous (IV) thrombolytic therapy in acute brain ischemia is strongly time-dependent,” the authors wrote. "Therapeutic yield is maximal in the first minutes after symptom onset and declines rapidly during the next 4.5 hours.”

Jeffrey L. Saver, MD, at the University of California, Los Angeles, and colleagues evaluated the characteristics of stroke patients who presented at an ED within the golden hour between April 1, 2003, and Dec. 30, 2007.

According to the researchers, “Each minute that reperfusion is delayed two million nerve cells die.” However, patients who present to the hospital in the first 60 minutes of onset have the greatest benefit of therapy.

During the study, researchers identified 253,148 ischemic stroke patients at 905 U.S. centers from the national Get With the Guidelines-Stroke database and assessed them over a 4.74-year time period. Of these patients, 28.3 percent presented within 60 minutes of onset of stroke, 31.7 percent presented in 61-180 minutes of onset and 40.1 percent presented more than 180 minutes after onset.

While patients were similar in age or sex, those who presented earlier were more likely to be non-Hispanic whites rather than blacks or Asians. And, those who presented within the golden hour presented at more hospitals in the West and Northeast.

According to national guidelines, hospitals who accept these stroke patients into their EDs should complete clinical and imaging evaluation and initiate lytic therapy within one hour of patient arrival. Additionally, the Joint Commission guidelines recommend that hospitals achieve a door-to-needle (DTN) time within 60 minutes in 80 percent of patients.

The researchers said that IV tPA was administered to 12,545 stroke patients who represented 11.8 percent of all direct ED-arriving stroke patients with documented last known well time (LKWTs) and 5 percent of all direct ED-arriving stroke patients.

Of these patients, 64.7 percent presented within 60 minutes, 34.5 percent within 61-180 minutes and 0.9 percent in over 180 minutes. Door-to-needle times for these patients were achieved in 60 minutes or less in 18.3 percent of patients.

While the authors say that the “proportion of golden hour patients treated with fibrinolytic therapy was substantial, the speed of initiation of treatment after hospital arrival was often below the recommended national target of a DTN time of 60 minutes or less.”

The researchers estimated that more than 55,000 Americans present each year within the first 60 minutes of onset of stroke. They said these findings show the need for improved health programs that create awareness and education of the importance of early action for stroke patients, because presenting during the golden hour lends the “greatest opportunity to save brain tissue during reperfusion.”

While the authors wrote that “there are many valid reasons to delay the start of therapy in early-arriving patients,” these are “all trumped by the one, overwhelming reason to hurry—the brain is dying all the while that these activities are taking place.”

This statement reiterates the importance of having patients report earlier, because even a patient arriving at the hospital at the second hour after onset could be at risk for slower response of IV tPA.

The authors said that targeted educational campaigns tailored to various race/ethnic groups would be beneficial in getting the public to understand stroke signs and the importance of early presentation at the ED.

Additionally, the authors said, “system interventions focused on continuous, iterative quality improvement can reduce DTN times for ischemic stroke patients.”

While the authors wrote that one in eight ischemic stroke golden hour patients presents directly to the ED, DTN times are still achieved in only one-fifth of these golden hour patients.

“These data also encourage reinvigorated hospital performance improvement activities to shorten DTN times in patients who present in the golden hour, when the volume of salvageable brain and the patient’s capacity to