Golden Hour Treatment With tPA (Tissue-Type Plasminogen Activator) in the BEST-MSU Study

Abstract

Background: Treatment of patients with acute ischemic stroke on mobile stroke units (MSUs) improves outcomes compared with management by standard emergency medical services ambulances and is associated with more patients treated with intravenous tPA (tissue-type plasminogen activator) in the first golden hour after last known normal. We explored the predictors and outcomes of first-hour treatment (FHT) compared with later treatment in an alternating-week cluster-controlled trial of MSUs. Methods: We analyzed all patients treated with intravenous tPA in the BEST-MSU Study (Benefits of Stroke Treatment Delivered by a Mobile Stroke Unit Compared to Standard Management by Emergency Medical Services). After stratifying by treatment timeframe, we identified factors associated with FHT. We performed adjusted analyses of the association between FHT and clinical outcome and modeled the shape of the relationship between last known normal–to–treatment time and excellent outcome. Results: Among 941 tPA-treated patients, 206 (21.8%) had lytic started within 60 minutes. Treatment on the MSU, older age, male sex, alert by 911, faster arrival on-scene and imaging, more severe stroke, atrial fibrillation, and absence of heart failure and pretreatment antihypertensive treatment were associated with FHT. Compared with later treatment, FHT was associated with higher adjusted odds ratio for 90-day modified Rankin Scale score of 0 to 1 (odds ratio, 1.87 [95% CI, 1.25–2.84]; P =0.003). Among FHT patients, 68% achieved a 90-day modified Rankin Scale of 0 or 1 or returned to their baseline status. FHT was not associated with higher risk of hemorrhage and was associated with reduced risk of treating neurovascular mimics. Conclusions: FHT almost doubles the odds of excellent clinical outcome without increased risk compared with later treatment, which supports the use of MSUs.

Who is in the emergency room matters when we talk about door-to-needle time: a single-center experience

“…10 For those patients who could be treated in their first hour of evolution, the odds of satisfactory clinical outcome at 3 months almost doubled. 11 In our experience, were 81%, of the patients were treated within a DTN time < 60, SNs presented a DTN 5.4 minutes shorter when compared to a neurologist from a different subspecialty and 17.4 minutes shorter when compared with EPs. These are important reductions if we consider that a 15minute decrease in DTN time is associated with a 5% lower odd of in-hospital mortality.…”

Mobile Stroke Units and Pursuit of Intravenous Tissue-Type Plasminogen Activator Treatment in the Golden Hour

“…Interestingly, after 2 hours the decline then plateaus; in the 121 to 270 minutes period, the predicted probability of mRS score of 0 to 1 at 90 days declined by only 0.1% every 5 minutes. 9 These data once again demonstrate the principle that the sooner tPA is administered the better patient clinical outcomes are, but they show that this is true even within the first hour of stroke onset.…”

“…18 In summary, MSUs have a proven benefit for tPA delivery to patients with acute ischemic stroke. The article by Mackey et al, 9 featured in this edition of Stroke, illustrates that the first hour after stroke onset is indeed the golden time for intravenous tPA treatment. However, by showing the rapid decline in the probability of achieving full recovery after stroke even within the golden hour, it also reminds us of the incessant need for speed.…”

“…In this edition of Stroke , Mackey and colleagues 9 present the results of a preplanned subanalysis of the BEST-MSU study, which explores the predictors and outcomes of first-hour intravenous tPA when compared with later treatment. They analyzed the cohort of 941 patients enrolled in BEST-MSU who received intravenous tPA, pooling across the 2 arms of the trial (MSU and non-MSU weeks), of whom 206 (21.8%) received first-hour treatment with intravenous tPA.…”

“…Finally, the subanalysis by Mackey only includes tPA-treated cases and so ignores the stroke patients who were included in BEST-MSU but did not receive intravenous tPA. 9…”