TY - JOUR
T1 - Association between Endovascular Therapy Time to Treatment and Outcomes in Patients with Basilar Artery Occlusion
AU - Joundi, Raed A.
AU - Sun, Jie Lena
AU - Xian, Ying
AU - Alhanti, Brooke
AU - Nogueira, Raul G.
AU - Bhatt, Deepak L.
AU - Fonarow, Gregg C.
AU - Saver, Jeffrey
AU - Schwamm, Lee H.
AU - Smith, Eric E.
N1 - Funding Information:
Dr Bhatt discloses the following relationships: advisory board for Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Janssen, Level Ex, Medscape Cardiology, MyoKardia, Novo Nordisk, PhaseBio, PLx Pharma, and Regado Biosciences; board of directors for Boston VA Research Institute, Society of Cardiovascular Patient Care, and TobeSoft; chair for American Heart Association Quality Oversight Committee; data monitoring committees for Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for PORTICO [Portico Re-sheathable Transcatheter Aortic Valve System US IDE Trial], funded by St Jude Medical, now Abbott), Cleveland Clinic (including for ExCEED [ExCEED: Centera THV System in Intermediate Risk Patients Who Have Symptomatic, Severe, Calcific, Aortic Stenosis], funded by Edwards), Contego Medical (chair, PERFORMANCE 2 [Protection Against Emboli During Carotid Artery Stenting Using the Neuroguard IEP System]), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for ENVISAGE [Edoxaban Compared to Standard Care After Heart Valve Replacement Using a Catheter in Patients With Atrial Fibrillation], funded by Daiichi Sankyo), and Population Health Research Institute; honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News and ACC.org; vice-chair, American College of Cardiology Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI [Evaluation of Dual Therapy With Dabigatran vs Triple Therapy With Warfarin in Patients With Atrial Fibrillation That Undergo a PCI With Stenting] steering committee funded by Boehringer Ingelheim; AEGIS-II [Study to Investigate CSL112 in Subjects With Acute Coronary Syndrome] executive committee funded by CSL Behring), Belvoir Publications (editor in chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), Duke Clinical Research Institute (clinical trial steering committees, including for PRONOUNCE [A Trial Comparing Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Advanced Prostate Cancer and Cardiovascular Disease], funded by Ferring Pharmaceuticals), HMP Global (editor in chief, Journal of Invasive Cardiology), guest editor and associate editor for Journal of the American College of Cardiology, K2P (co-chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS [Cardiovascular Outcomes for People Using Anticoagulation Strategies] operations committee, publications committee, steering committee, and US national coleader, funded by Bayer), Slack Publications (chief medical editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), WebMD (CME steering committees); other from Clinical Cardiology (deputy editor), NCDR-ACTION (National Cardiovascular Data Registry–Acute Coronary Treatment and Intervention Outcomes Network) registry steering committee (chair), Veterans Affairs CART (Cardiovascular Assessment, Reporting, and Tracking) research and publications committee (chair); research funding from Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Lexicon, Lilly, Medtronic, MyoKardia, Novo Nordisk, Owkin, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic, and The Medicines Company; royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); site coinvestigator for Abbott, Biotronik, Boston Scientific, CSI, St Jude Medical (now Abbott), and Svelte; trustee for American College of Cardiology; and unfunded research for FlowCo, Merck, and Takeda. Dr Nogueira reports consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Imperative Care, Medtronic, Phenox, Prolong Pharmaceuticals, Stryker Neurovascular, and Synchron, and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, and Perfuze. Dr Fonarow reports research funding from the Patient-Centered Outcomes Research Institute, is a member of the GWTG-Stroke steering committee, and is an employee of the University of California Regents, which has a patent on an endovascular device. Dr Xian reports research grants from the National Institute of Aging (R01AG062770 and R01AG066672), Genentech, Janssen, and DSI. Dr Schwamm reports the following relationships relevant to research grants or companies that manufacture products for thrombolysis or thrombectomy even if the interaction involves nonthrombolysis products: scientific consultant regarding trial design and conduct to Genentech (late window thrombolysis) and member of steering committee (TIMELESS [Tenecteplase in Stroke Patients Between 4.5 and 24 Hours]); consultant on user interface design and usability to LifeImage; member of data safety monitoring boards for Penumbra (MIND: Artemis in the Removal of Intracerebral Hemorrhage) and Diffusion Pharma (PHAST-TSC [Efficacy and Safety of Trans Sodium Crocetinate (TSC) for Treatment of Suspected Stroke]); serving as national PI for Medtronic (Stroke AF [Rate of Atrial Fibrillation Through 12 Months in Patients With Recent Ischemic Stroke of Presumed Known Origin]); national PI, late window thrombolysis trial, National Institute of Neurological Disorders and Stroke (P50NS051343, MR WITNESS [A Study of Intravenous Thrombolysis With Alteplase in MRI-Selected Patients] and alteplase provided free of charge to Massachusetts General Hospital as well as supplemental per-patient payments to participating sites by Genentech); and site PI, StrokeNet Network, National Institute of Neurological Disorders and Stroke (New England Regional Coordinating Center, U24NS107243). Dr Smith reports royalties from UpToDate and consulting fees from Alnylam, Biogen, and Javelin. The other authors report no disclosures.
Funding Information:
The Get With The Guidelines–Stroke (GWTG-Stroke) program is provided by the American Heart Association/American Stroke Association. GWTG-Stroke is sponsored, in part, by Novartis, Boehringer Ingelheim and Eli Lilly Diabetes Alliance, Novo Nordisk, Sanofi, AstraZeneca, Bayer, and Alexion Pharmaceuticals. The study was supported by a Young Investigator Database Seed Grant awarded to Dr Joundi.
Publisher Copyright:
© 2022 Lippincott Williams and Wilkins. All rights reserved.
PY - 2022/3/22
Y1 - 2022/3/22
N2 - Background: Basilar artery occlusion (BAO) is a devastating condition without definitive evidence to guide treatment. Whereas the association between faster treatment times with endovascular therapy (EVT) and better outcomes in anterior circulation is well established, whether this relationship exists for patients with BAO is not well delineated. Methods: We used individual-level patient data from the Get With The Guidelines-Stroke nationwide US registry prospectively collected from January 2015 to December 2019. We identified individuals with BAO treated with EVT within 24 hours of symptom onset. The primary outcomes examined were in-hospital mortality, discharge home, ambulatory at discharge, independent at discharge (modified Rankin Scale score 0 to 2), substantial reperfusion (modified Thrombolysis in Cerebral Infarction score 2b or 3), and symptomatic intracranial hemorrhage. Using logistic regression models, we evaluated the association between time from symptom onset to treatment with EVT and outcomes. Results: Among 3015 patients with BAO treated with EVT, the mean age was 65.9 years, 38.8% were women, and the median National Institutes of Health Stroke Scale score at presentation was 17 (interquartile range, 8-26). Median onset to EVT time was 406 minutes (interquartile range, 252-688). From 2015 to 2019, there was an overall increase in the median onset to EVT times (380-411 minutes; P=0.016) but no significant change in the proportion of patients treated within 6 hours of symptom onset (48.4%-44.0%; P=0.17). After risk adjustment for patient and hospital-level factors, there were significantly lower odds of in-hospital mortality (adjusted odds ratio [aOR], 0.55 [95% CI, 0.45-0.68]) and symptomatic intracranial hemorrhage (aOR, 0.52 [95% CI, 0.32-0.84]) and significantly higher odds of ambulation at discharge (aOR, 1.72 [95% CI, 1.37-2.16]), discharge home (aOR, 2.19 [95% CI, 1.73-2.77]), and independence at discharge (aOR, 2.21 [95% CI, 1.66-2.95]) when onset to EVT time was ≤6 hours compared with >6 hours. The fastest decay in good outcomes per hour occurred within 6 hours of symptom onset. Conclusions: Among patients receiving EVT for BAO, faster treatment from symptom onset was associated with improved outcomes. These findings support efforts to achieve rapid treatment with EVT for patients with BAO.
AB - Background: Basilar artery occlusion (BAO) is a devastating condition without definitive evidence to guide treatment. Whereas the association between faster treatment times with endovascular therapy (EVT) and better outcomes in anterior circulation is well established, whether this relationship exists for patients with BAO is not well delineated. Methods: We used individual-level patient data from the Get With The Guidelines-Stroke nationwide US registry prospectively collected from January 2015 to December 2019. We identified individuals with BAO treated with EVT within 24 hours of symptom onset. The primary outcomes examined were in-hospital mortality, discharge home, ambulatory at discharge, independent at discharge (modified Rankin Scale score 0 to 2), substantial reperfusion (modified Thrombolysis in Cerebral Infarction score 2b or 3), and symptomatic intracranial hemorrhage. Using logistic regression models, we evaluated the association between time from symptom onset to treatment with EVT and outcomes. Results: Among 3015 patients with BAO treated with EVT, the mean age was 65.9 years, 38.8% were women, and the median National Institutes of Health Stroke Scale score at presentation was 17 (interquartile range, 8-26). Median onset to EVT time was 406 minutes (interquartile range, 252-688). From 2015 to 2019, there was an overall increase in the median onset to EVT times (380-411 minutes; P=0.016) but no significant change in the proportion of patients treated within 6 hours of symptom onset (48.4%-44.0%; P=0.17). After risk adjustment for patient and hospital-level factors, there were significantly lower odds of in-hospital mortality (adjusted odds ratio [aOR], 0.55 [95% CI, 0.45-0.68]) and symptomatic intracranial hemorrhage (aOR, 0.52 [95% CI, 0.32-0.84]) and significantly higher odds of ambulation at discharge (aOR, 1.72 [95% CI, 1.37-2.16]), discharge home (aOR, 2.19 [95% CI, 1.73-2.77]), and independence at discharge (aOR, 2.21 [95% CI, 1.66-2.95]) when onset to EVT time was ≤6 hours compared with >6 hours. The fastest decay in good outcomes per hour occurred within 6 hours of symptom onset. Conclusions: Among patients receiving EVT for BAO, faster treatment from symptom onset was associated with improved outcomes. These findings support efforts to achieve rapid treatment with EVT for patients with BAO.
KW - basilar artery
KW - stroke
KW - therapeutics
KW - time-to-treatment
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U2 - 10.1161/CIRCULATIONAHA.121.056554
DO - 10.1161/CIRCULATIONAHA.121.056554
M3 - Article
C2 - 35050693
AN - SCOPUS:85127100080
SN - 0009-7322
VL - 145
SP - 896
EP - 905
JO - Circulation
JF - Circulation
IS - 12
ER -