Consent delay common reason for lag in tPA administration
Consent delay is one of the most common reasons stroke patients in New York State don't receive tissue plasminogen activator (tPA) within the first hour (called the "Golden Hour") of hospital arrival, researchers reported at the American Stroke Association's International Stroke Conference 2015.
Hospitals target administration of the clot-busting drug within 60 minutes of stroke patients' arrivals, but miss the goal in more than 50 percent of cases. Researchers studied reasons for tPA delays among 22,620 ischemic stroke patients at 120 New York hospitals.
Delays in tPA administration occurred in 1,145 patients, and reasons for those delays were given in 1,116 patients. Among those they found:
- Patient/family consent was a factor in delay in 239, or 21 percent of cases.
- Management of other emergency health conditions caused delays, which occurred in 21 percent of cases.
- Women were much more likely to experience delay due to patient/family consent than men.
- Delay due to patient/family consent was more likely on weekends than weekdays.
This state-level study suggests training and tools to improve and shorten the consent process might reduce delays in tPA treatment. Researchers should delve into why these delays occur more with female stroke patients and on weekends, researchers said.
Sheree Murphy, M.S., C.P.H.Q., American Heart/American Stroke Association, New York, N.Y.
Abstract 206 and Abstract 14
*3181/206 contains updated numbers not in the abstract.
Insertable cardiac monitoring cost-effectively detects post-stroke irregular heartbeat
Insertable cardiac monitoring (ICM) cost-effectively detects irregular heartbeat or atrial fibrillation episodes and episode duration in patients who have had cryptogenic strokes (cause of stroke unknown), according to two studies presented at the American Stroke Association's International Stroke Conference 2015.
Doctors cannot determine the cause of ischemic stroke in 20 percent to 40 percent of cases, despite conventional diagnostic tests. But they need to document atrial fibrillation in order to prescribe anticoagulant therapy to reduce recurrent stroke risk.
ICMs are inserted under the skin in a minimally invasive procedure to monitor patients' heartbeats for three years, compared to electrocardiograms, which are tests given on the spot in doctors' offices or hospitals, and Holter monitors, which patients wear from 24 hours to several days.
To help determine if an ICM is effective, researchers analyzed 1,247 cryptogenic stroke patients who received an ICM device post stroke (abstract 206).
- Atrial fibrillation detection rate in the study population was 12.2 percent at 182 days; this was 37 percent higher than what was found in a recent randomized controlled trial (CRYSTAL AF) at the same time.
- ICM detected the duration of each atrial fibrillation episode.
- Half of the patients with detected atrial fibrillation had an episode that was at least 3.4 hours in duration.
- Among the patients with atrial fibrillation, 25 percent had an episode that was longer than 11.8 hours.
Atrial fibrillation episodes of clinically important duration were detected with continuous ICM monitoring in a notable proportion of cryptogenic stroke patients, despite a relatively brief follow-up, the researchers said. These "real-world" data confirm what was observed in the CRYSTAL AF study, and researchers suggest that ICMs may have even greater clinical utility in detecting AF in real-world practice than in clinical trials.
In other research (abstract 14), scientists analyzed data from previous studies to determine if detecting atrial fibrillation with an ICM in cryptogenic stroke patients is cost-effective compared to standard of care.
- ICM was associated with fewer recurrent strokes and increased quality of life.
- While stroke-related costs were lower in the ICM group, overall costs were higher than in the standard of care group.
When researchers studied the ratio of added costs to added health-related quality of life benefits, they determined ICM use would be considered by payers to be a good value for the money and cost effective.
Paul Ziegler, M.S., Medtronic, Mounds View, Minn. (abstract 206);
Alex Diamantopoulos, Symmetron Limited, Borehamwood, UK (abstract 14);
Chronic kidney disease ups risk of cognitive decline years after stroke
Chronic kidney disease is associated with increased signs of brain aging and is a predictor of cognitive decline years after stroke or transient ischemic attack (TIA), according to research presented at the American Stroke Association's International Stroke Conference 2015.
There has been little research on the relationship between chronic kidney disease and post-stroke declines in brain function, such as memory and learning.
In a study of 462 people who had mild to moderate ischemic strokes or TIAs, researchers found decreased renal (kidney) function is associated with markers of small vessel disease in the brain and cognitive decline. In fact, those who had decreased renal function at hospital admission were 40 percent more likely to develop cognitive impairment two years following stroke than were people with normal kidney function at admission.
Chronic kidney disease may contribute to accelerated brain aging and post-stroke cognitive decline, suggesting a new target for early intervention, researchers said.
Presenter: Natan Bornstein, Ph.D., M.D., Tel-Aviv Medical Center, Israel.
Einor Ben-Assayag, Ph.D., Tel-Aviv Sorasky Medical Center, Israel.
Abstract 92 and Abstract 68
DNR status and palliative care underuse negatively affect bleeding stroke patients
Do-not-resuscitate (DNR) status and the under use of palliative care negatively impact best care practices in patients who survive nontraumatic intracerebral hemorrhage (bleeding within the brain), according to two studies presented at the American Stroke Association's International Stroke Conference 2015.
Intracerebral hemorrhage is a life-threatening bleeding stroke associated with substantial health issues and death risk. Studies have found DNRs negatively impact patients who survive this type of bleeding stroke, probably because of the inactive health management associated with the orders.
Researchers in one study (abstract 92) found demographic, social and regional characteristics impact whether people have DNRs. They analyzed the records of nearly 25,800 patients who suffered non-traumatic intracerebral hemorrhage in 2011 and 2012. Of those, 18 percent had DNR orders placed. They found:
- The likelihood of placing DNR orders was 1.2 times higher in women than men.
- The odds of placing DNRs were 1.6 times more likely among Caucasians and 1.2 times more likely among Hispanics than African Americans.
- The likelihood of placing DNRs was 1.1 times higher among Medicare and Medicaid patients and 1.1 times higher among self- or no-pay patients, than those with private insurance.
- The odds of having DNR orders were 1.6 times more among the patients at hospitals in the West region of the United States than the Northeast. Other regions were not significantly different from the Northeast.
The reasons for these DNR use variations should be explored, the researchers said.
In another study (abstract 68), researchers examined whether patients with a poor prognosis after intracerebral hemorrhage received a palliative care consult while in the hospital. Palliative care, which focuses on managing pain and symptoms near the end of life, is an essential part of care for intracerebral hemorrhage patients with poor prognosis.
The researchers found that of 99 intracerebral patients who died or were discharged to hospice, only 23 percent received a palliative care consultation. Among the most severe ICH patients, only 28 percent received a palliative care consult, despite an expected 30-day mortality of 97 percent.
This raises concerns about palliative care underuse among patients who might benefit most, they said.
Vishal B. Jani, M.D., Michigan State University, East Lansing, Mich. (abstract 92);
April Sisson, University of Alabama at Birmingham, Birmingham, Ala. (abstract 68 );
Gender helps identify caregivers at poor health risk
Female caregivers are more likely than male caregivers to report poor health, especially when they perceive their roles as difficult or life changing, according to research presented at the American Stroke Association's International Stroke Conference 2015.
Caregiving commonly results in caregivers' poor health. And women report more burden than men in similar caregiving situations. But it's unclear whether gender impacts the association between caregiving and poor health.
Researchers studied whether gender is associated with risk of poor health among caregivers based on caregivers' relationships (spouse or non-spouse) with stroke patients and whether caregivers are the same or opposite gender as patients. Researchers surveyed 277 caregivers of stroke survivors after the first two months, post-stroke.
- Caregiving for longer periods of time, difficulty of caregiving tasks and negative changes in life were highly associated with poor health status.
- Female spousal caregivers reported strong links between difficulty of caregiving tasks and poor health status, and between negative perception of life changes due to caregiving and poor health status. The same was not true for male spousal caregivers.
- Similar results were found for caregivers who were the opposite gender from patients.
Caregiver gender and relationship with stroke patients might help identify caregivers at high risk of poor health. More study is needed to examine the dynamics that influence caregiving relationships to individualize interventions, researchers said.
Misook L. Chung, Ph.D., R.N., University of Kentucky, Lexington, Ky.;
Abstract W MP33
Many mild stroke patients considered "too good to treat" may actually benefit from tPA
Stroke patients with mild symptoms might be eligible to receive the clot-busting drug tissue plasminogen activator (tPA), but often don't receive the therapy because they are deemed "too good to treat." However, many of these patients don't fare well after stroke, according to research presented at the American Stroke Association's International Stroke Conference 2015.
Using the Get With The Guidelines database from Boston's Massachusetts General Hospital, researchers analyzed 2,745 consecutive stroke admissions (01/2009 - 07/2013). Researchers studied which "too-good-to treat"-patients should be considered for tPA because of their risk of poor health or death.
- Of the 238 stroke patients studied who arrived in time to receive tPA but did not receive it because their symptoms were too mild or they were rapidly improving, 89 did not do well and might have benefitted from tPA.
- Only 62 percent of those studied were discharged home. Nearly 27 percent went to inpatient rehabilitation facilities; 8.4 percent to skilled nursing facilities; and more than 2 percent either died or went to hospice.
- Risk factors for having poor outcome post-stroke in this group of patients include: being elderly; having more severe strokes; being Hispanic; and having a stroke that affects both hemispheres of the brain. Hispanics, for example, were 11.43 times more likely than non-Hispanics to suffer with poor health after stroke.
More research is needed to better identify which patients might do poorly without tPA treatment, researchers said.
Khawja A. Siddiqui, M.D., Massachusetts General Hospital, Boston, Mass.;