Shorter Door-to-Needle Time Means Better Long-Term Outcomes in Acute Ischemic Stroke

Add lower all-cause mortality and all-cause readmission at one year to the list of confirmed benefits from shorter door-to-needle times for patients aged 65 or older with acute ischemic stroke, concludes a new study published in the Journal of the American Medical Association. The findings support efforts to shorten time to treatment with intravenous thrombolytic therapy for stroke such as Target: Stroke, a decade-long national quality initiative from the American Stroke Association and American Heart Association.

“We already knew that shorter time from hospital arrival to administration of thrombolytic therapy improves functional outcomes at discharge and at 90 days,” says Shumei Man, MD, PhD, first author of the study and Medical Director of the Thrombectomy-Capable Stroke Center at Cleveland Clinic Fairview Hospital. “These results now tell us that the benefits persist at least a year afterwards and should prompt further efforts to reduce door-to-needle time across all health systems, from rural hospitals to academic medical centers.”

Large cohort, consistent results

This retrospective cohort study included 61,426 patients with acute ischemic stroke from Get with the Guidelines® – Stroke participating hospitals from 2006 through 2016 who were treated with tissue plasminogen activator (tPA) within 4.5 hours of symptom onset. Median patient age was 80 years, and median door-to-needle time was 65 minutes (interquartile range, 49-88). Primary outcomes included one-year all-cause mortality, all-cause readmission, and an all-cause mortality or readmission composite. Secondary outcomes were one-year cardiovascular readmission and readmission for recurrent stroke.

The lowest mortality and readmission rates were observed among patients with door-to-needle times of 45 minutes or less, followed by 60 minutes or less (with the exception of readmission for recurrent stroke, which did not differ among groups). The 55.9% of patients with door-to-needle times exceeding 60 minutes had significantly higher rates of all primary outcomes at one year relative to patients treated within 60 minutes, as follows:

• Mortality, 35.8% vs. 32.1% (adjusted HR [aHR] = 1.11; 95% CI, 1.07-1.14)
• All-cause readmission, 41.3% vs. 39.1% (aHR = 1.07; 95% CI, 1.04-1.10)
• Mortality/readmission composite, 56.8% vs. 53.1% (aHR = 1.08; 95% CI, 1.05-1.10)

This analysis, which the researchers note had substantially more power and longer follow-up than the clinical trials to date, demonstrated that each 15-minute increase in time to therapy was significantly associated with higher one-year mortality (aHR = 1.04; 95% CI, 1.02-1.05) through, but not after, 90 minutes, as well as higher all-cause readmissions (aHR = 1.02; 95% CI, 1.01-1.03) and mortality/readmission composite (aHR = 1.02; 95% CI, 1.01-1.03). Cardiovascular readmissions, but not recurrent stroke readmissions, were also significantly associated with door-to-needle time.

Accelerating treatment times

“This new retrospective study allows the stroke care community to focus our existing efforts a bit,” says Dr. Man. “We were already working to shorten door-to-needle times based on what we know about short-term benefits. The sweet spot of 45 minutes or less confers benefit in the primary and some secondary outcomes measured in this study, and results encourage a redoubling of what we’re already doing.”

Get with the Guidelines – Stroke was launched by the American Heart Association/American Stroke Association to support continuous quality improvement across the U.S. It collects clinical data on all patients hospitalized for acute ischemic stroke or transient ischemic attack at participating hospitals.

“Using this database, we have seen lower hemorrhagic transformation and in-hospital mortality rates, as well as higher discharge-to-home rates from our efforts to shorten door-to-needle time,” says Dr. Man. “Now we know that these benefits are persisting for patients beyond our walls, which makes our efforts all the more worthwhile.”

At Cleveland Clinic, those efforts include initiatives like expanded use of its mobile stroke treatment unit, which in 2018 was able to administer intravenous tPA 38 minutes faster, on average, than if a patient was transported to an emergency department using a traditional ambulance. And for acute ischemic stroke patients treated in the emergency department in 2018, Cleveland Clinic achieved a door-to-needle time within the Get with the Guidelines – Stroke target in 100% of cases. Details on these and other Cleveland Clinic stroke outcomes data are available here.