TY - JOUR
T1 - Frequency, characteristics, and outcomes of endovascular thrombectomy in patients with stroke beyond 6 hours of onset in US clinical practice
AU - Zachrison, Kori S.
AU - Schwamm, Lee H.
AU - Xu, Haolin
AU - Matsouaka, Roland
AU - Shah, Shreyansh
AU - Smith, Eric E.
AU - Xian, Ying
AU - Fonarow, Gregg C.
AU - Saver, Jeffrey
N1 - Funding Information:
Dr Zachrison reports grants from the Agency for Healthcare Research and Quality during the conduct of the study; grants from National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke (NINDS), other from the American College of Emergency Physicians, and grants from Controlled Risk Insurance Company (CRICO) outside the submitted work. Dr Schwamm reports relationships relevant to research grants or companies that manufacture thrombolysis or thrombectomy products even if the interaction involves nonthrombolysis products: scientific consultant regarding trial design and conduct to Genentech (late-window thrombolysis) and steering committee membership (TIMELESS [Tenecteplase in Stroke Patients Between 4.5 and 24 Hours]; https://www.clinicaltrials.gov ; Unique identifier: NCT03785678); consultant to LifeImage and Massachusetts Dept of Public Health; member of Data Safety Monitoring Boards (DSMB) for Penumbra (MIND [Artemis in the Removal of Intracerebral Hemorrhage]; https://www.clinicaltrials.gov ; Unique identifier: NCT03342664) and Diffusion Pharma (PHAST-TSC [Pre-Hospital Administration of Stroke Therapy - Trans Sodium Crocetinate]; https://www.clinicaltrials.gov ; Unique identifier: NCT03763929); National principal investigator for Medtronic (Stroke AF [Stroke Atrial Fibrillation]; https://www.clinicaltrials.gov ; Unique identifier: NCT02700945); National Co-principal investigator, late-window thrombolysis trial, NINDS (P50NS051343, MR WITNESS [A Study of Intravenous Thrombolysis With Alteplase in MRI-Selected Patients]; https://www.clinicaltrials.gov ; Unique identifier: NCT01282242; alteplase provided free of charge to Massachusetts General Hospital and supplemental per-patient payments to participating sites by Genentech); Site principal investigator, StrokeNet Network NINDS (New England Regional Coordinating Center U24NS107243). Dr Smith reports royalties from UpToDate; and consulting fees from Alnylam, Bayer, Biogen, and Javelin. Dr Xian reports grants from the American Heart Association, personal fees from Boehringer Ingelheim, grants from Genentech, and grants from the National Institute on Aging during the conduct of the study. Dr Fonarow reports research funding from Patient Centered Outcomes Research Institute (PCORI), member Get With The Guidelines (GWTG) Steering Committee, and employee of University of California Regents which has a patent on an endovascular device. Dr Saver reports personal fees from Stryker, personal fees from Medtronic, personal fees from Cerenovus, and personal fees from Rapid Medical outside the submitted work. The other authors report no conflicts.
Funding Information:
The Get With The Guidelines (GWTG)–Stroke program is provided by the American Heart Association/American Stroke Association. GWTG-Stroke is sponsored, in part, by Novartis, Boehringer Ingelheim Lilly, Novo Nordisk, Sanofi, AstraZeneca, Bayer, and Portola Pharmaceuticals. Dr Zachrison reports support from the Agency for Healthcare Research & Quality (K08 HS024561).
Publisher Copyright:
© 2021 American Heart Association, Inc.
PY - 2021/12/1
Y1 - 2021/12/1
N2 - BACKGROUND AND PURPOSE: In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines–Stroke clinical registry. METHODS: We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines–Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes. RESULTS: We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3–7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%–38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours. CONCLUSIONS: EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.
AB - BACKGROUND AND PURPOSE: In 2018, 2 randomized controlled trials showed the benefit of endovascular thrombectomy (EVT) in acute ischemic stroke patients treated 6 to 24 hours from last known well using imaging-guided selection. However, little is known about outcomes in contemporary nontrial settings. We assessed the frequency of EVT and outcomes beyond 6 hours in the US Get With The Guidelines–Stroke clinical registry. METHODS: We analyzed all acute ischemic stroke patients treated with EVT between January 1, 2009 and October, 1, 2018, at Get With The Guidelines–Stroke hospitals in the United States. We assessed trends over time in frequency of EVT beyond 6 hours, compared patient characteristics and outcomes between those treated within versus beyond 6 hours, and evaluated the associations between EVT time and outcomes. RESULTS: We identified 53 702 patients at 697 sites treated with EVT during the study period. Treatment after 6 hours from last known well occurred in 17 720 (33%) of all 53 702 EVT cases (median 4.7 hours, interquartile range, 3.3–7 hours). The proportion of EVT cases treated after 6 hours from last known well varied widely across sites (median 30%, interquartile range, 24%–38%). Compared with patients treated within 6 hours, those treated beyond six hours were younger, less likely to have atrial fibrillation, less likely to arrive by ambulance, had lower stroke severity, were less likely to be anticoagulated, and more likely to be treated at centers with higher EVT volumes. After adjusting for patient and hospital characteristics, patients receiving EVT beyond 6 hours had less favorable in-hospital mortality, ambulation at discharge, and discharge disposition compared to those treated within 6 hours. CONCLUSIONS: EVT is frequently performed for patients with ischemic stroke after 6 hours from last known well, accounting for one-third of cases nationally, and adjusted functional outcomes at discharge are worse in these patients compared to those treated with EVT within 6 hours. Further efforts are needed for optimal EVT outcomes in clinical practice settings.
KW - Hospitals
KW - Ischemic stroke
KW - Mortality
KW - Reperfusion
KW - Thrombectomy
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U2 - 10.1161/STROKEAHA.121.034069
DO - 10.1161/STROKEAHA.121.034069
M3 - Article
C2 - 34470490
AN - SCOPUS:85121054750
SN - 0039-2499
VL - 52
SP - 3805
EP - 3814
JO - Stroke
JF - Stroke
IS - 12
ER -