Patient Refusal of Thrombolytic Therapy for Suspected Acute Ischemic Stroke

Abstract

Objective To determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA. Methods Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0–1), good (mRS: 0–2), and poor (mRS: 3–6). Results Over 7.5 years, thirty (4.2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0.63, 95% CI 0.50 – 0.79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1.02, 95% CI 1.01 – 1.03), lower NIHSS (OR 1.11, 95% CI 1.03 – 1.18), a higher proportion of stroke mimics (OR 17.61, 95% CI 6.20 – 50.02) and shorter hospital stay (OR 1.32, 95% CI 1.09 – 1.61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1.37, 95% CI 1.06 – 1.78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1.61, 95% CI 0.69 – 3.73). Conclusion The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out six refusal patients (16.6%) had a stroke mimic.

Legal medicine implications in fibrinolytic therapy of acute ischemic stroke

“…Of the cases presented in our study, the patients who refused the fibrinolytic treatment invoked the fear of hemorrhagic risk. In the hospital where all the cases were registrated, we found a decline rate of approximately 2% over the study period, a smaller percentage compared to those reported by other studies [35]. We have also found that there has been a downward trend in refusal over the last few years.…”

“…We have also found that there has been a downward trend in refusal over the last few years. The experience accumulated by physicians over time (both in conducting the thrombolysis procedure and in relation to patients or their legal representatives), the results obtained and the recent scientific evidence that reported t-PA safety for patients with mild symptoms too [36] may influence positively the doctors’ behavior and, implicitly, the increase of patients’ confidence in the benefits of this specific therapy [35]. Also, the recent efforts of the Ministry of Health to raise awareness among the public about the alarming signs of ischemic stroke, showing the benefits of thrombolysis, and the need for treatment may be associated with this decrease.…”

Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke

“…The observed prevalence of tPA declination in this national cohort is less than previously reported in single-center or regional studies (4.2%-7.5% declined tPA). 10,15,16 This may be due to an overestimation of treatment declination in smaller sample cohorts, the impact of national efforts to improve tPA use among GWTG-Stroke participating hospitals, or underlying regional variation in declining tPA across the country. 10 Despite the lower overall prevalence of tPA declination, the current study provides further evidence in support of previous observations that non-Hispanic Black patients with AIS are more likely to decline tPA than non-Black patients.…”

“…In addition, in patients presenting with an NIHSS score <15, lower NIHSS score was associated with a greater risk of tPA declination, consistent with other published reports. 10,15 Patients with minor deficits may perceive risks of disability differently from patients with more debilitating deficits, and this perception may affect decision-making about treatment with tPA. Declining care was also more likely in patients with very severe stroke (NIHSS score >15).…”

Improving timely treatment with a stroke emergency map: The case of northern China

“…Additionally, we observed that patients with atrial fibrillation or greater stroke severity were more likely to use the EMS. For these patients, the neurologist evaluation (Vahidy, Rahbar, Lal, Grotta, & Savitz, 2015) and the patients’ caregivers’ concerns about the risk of thrombolysis may cause delays for treatment. Standardized training has been implemented to teach clinicians to be more persuasive when educating patients and caregivers regarding the importance of timely intervention for stroke.…”