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Circulation Journal : Official Journal... Jun 2017
Topics: Humans; Hydrogen; Myocardial Infarction; Myocardial Reperfusion; Translational Research, Biomedical
PubMed: 28566655
DOI: 10.1253/circj.CJ-17-0520 -
Expert Review of Neurotherapeutics May 2016Ischemic stroke is a major cause of death and disability and intravenous thrombolysis has been the only approved acute reperfusion therapy (RT) for many years. (Review)
Review
BACKGROUND
Ischemic stroke is a major cause of death and disability and intravenous thrombolysis has been the only approved acute reperfusion therapy (RT) for many years.
METHODS
Seven randomized-controlled clinical trials (RCTs) evaluating the safety and efficacy of endovascular therapy in patients with acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) have been recently published.
RESULTS
These studies have changed the treatment paradigm by establishing mechanical thrombectomy (MT) as the most effective acute stroke therapy for improving functional outcome in anterior circulation ELVO with a NNT of 6.
CONCLUSIONS
The present review will critically evaluate the results of these RCTs and of the existing meta-analyses investigating the safety and efficacy of endovascular therapy for AIS. Points of debate such as acute stroke imaging, posterior circulation stroke and general anesthesia will be addressed. We will also discuss health policies aiming to increase the availability of endovascular treatment for stroke patients.
Topics: Brain Ischemia; Endovascular Procedures; Humans; Reperfusion; Stroke; Thrombectomy
PubMed: 26988872
DOI: 10.1586/14737175.2016.1168297 -
Journal of the American Heart... Feb 2019See Editorial by Cenko et al.
See Editorial by Cenko et al.
Topics: Female; Heart; Humans; Male; Myocardial Infarction; Myocardial Reperfusion; Thrombolytic Therapy
PubMed: 30767600
DOI: 10.1161/JAHA.118.011835 -
Resuscitation Apr 2021The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care...
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
Topics: Adult; Cardiopulmonary Resuscitation; Consensus; Critical Care; Heart Arrest; Humans; Myocardial Reperfusion
PubMed: 33773827
DOI: 10.1016/j.resuscitation.2021.02.012 -
Stroke Nov 2020More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice...
BACKGROUND AND PURPOSE
More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated.
METHODS
Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0-5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage.
RESULTS
Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59-79] years; median NIHSS score of 2 [interquartile range, 1-4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71-2.13], <0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09-1.83], <0.001).
CONCLUSIONS
In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.
Topics: Age Factors; Aged; Aged, 80 and over; Comorbidity; Diabetes Mellitus; Emergency Service, Hospital; Endovascular Procedures; Ethnicity; Female; Health Facility Size; Hospital Mortality; Hospitalization; Hospitals; Hospitals, Rural; Hospitals, Teaching; Hospitals, Urban; Humans; Ischemic Stroke; Male; Middle Aged; Patient Discharge; Patient Transfer; Recovery of Function; Renal Insufficiency, Chronic; Reperfusion; Retrospective Studies; Severity of Illness Index; Thrombectomy; Thrombolytic Therapy; Treatment Outcome; United States
PubMed: 33081604
DOI: 10.1161/STROKEAHA.120.030898 -
Stroke Jul 2022Reperfusion therapies (thrombolysis and thrombectomy) are of paramount importance for the recovery after ischemic stroke. We aimed to investigate if socioeconomic status...
BACKGROUND
Reperfusion therapies (thrombolysis and thrombectomy) are of paramount importance for the recovery after ischemic stroke. We aimed to investigate if socioeconomic status (SES) was associated with the chance of receiving reperfusion therapy for ischemic stroke in a country with tax-funded health care.
METHODS
This nationwide register-based cohort study included patients with ischemic stroke registered in the Danish Stroke Registry between 2015 and 2018. SES was determined by prestroke educational attainment, income level, and employment status. Data on SES was obtained from Statistics Denmark and linked on an individual level with data from the Danish Stroke Registry. Risk ratios (RR) for receiving reperfusion therapies were calculated using univariate and multivariable Poisson regression with robust variance.
RESULTS
A total of 37 187 ischemic stroke patients were included. Low SES, as defined by education, income and employment status, was associated with lower treatment rates. The socioeconomic gradient was most pronounced according to employment status, with intravenous thrombolysis rates of 23.7% versus 15.8%, and thrombectomy rates of 5.1% versus 2.8% for employed versus unemployed patients. When the analyses were restricted to patients with timely hospital arrival, and adjusted for age, sex and immigrant status, low SES according to income and employment remained unfavorable for the likelihood of receiving intravenous thrombolysis: adjusted RR, 0.90 (95% CI, 0.86-0.95) for low versus high income, and adjusted RR, 0.77 (95% CI, 0.71-0.84) for unemployed versus employed patients. Similarly, low SES according to income and employment status remained unfavorable for the likelihood of receiving thrombectomy: adjusted RR, 0.83 (95% CI, 0.72-0.95) for low versus high income and adjusted RR, 0.68 (95% CI, 0.53-0.88) for unemployed versus employed patients.
CONCLUSIONS
Socioeconomic inequalities in reperfusion treatment rates among ischemic stroke patients prevail, even in a country with tax-funded universal health care.
Topics: Brain Ischemia; Cohort Studies; Humans; Ischemic Stroke; Reperfusion; Social Class; Stroke; Thrombectomy; Treatment Outcome
PubMed: 35579017
DOI: 10.1161/STROKEAHA.121.037687 -
Journal of Integrative Neuroscience Mar 2023Early neurological deterioration (END), generally defined as the increment of National Institutes of Health Stroke Scale (NIHSS) score ≥4 within 24 hours, lead to poor... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Early neurological deterioration (END), generally defined as the increment of National Institutes of Health Stroke Scale (NIHSS) score ≥4 within 24 hours, lead to poor clinical outcome in acute ischemic stroke (AIS) patients receiving reperfusion therapies including intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). This systematic review and meta-analysis aimed to explore multiple predictors of END following reperfusion therapies.
METHODS
We searched PubMed, Web of Science and EBSCO for all studies on END in AIS patients receiving IVT and/or EVT published between January 2000 and December 2022. A random-effects meta-analysis was conducted and presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The quality of each included studies was assessed by calculating a total score according to the STROBE or CONSORT criteria. Publication bias and heterogeneity were also evaluated using the Eggers/Peters test, funnel plots and sensitivity analysis.
RESULTS
A total of 29 studies involving 65,960 AIS patients were included. The quality of evidence is moderate to high, and all studies have no publication bias. The overall incidence of END occurring after reperfusion therapy in AIS patients was 14% ((95% confidence intervals (CI), 12%-15%)). Age, systolic blood pressure (SBP), glucose levels at admission, the onset to treatment time (OTT), hypertension, diabetes mellitus, arterial fibrillation, and internal cerebral artery occlusion were significantly associated with END following reperfusion therapy.
CONCLUSIONS
Numerous factors are associated with END occurrence in AIS patients receiving reperfusion therapy. Management of the risk factors of END may improve the functional outcome after reperfusion treatment.
Topics: Humans; Stroke; Brain Ischemia; Ischemic Stroke; Fibrinolytic Agents; Treatment Outcome; Reperfusion
PubMed: 36992598
DOI: 10.31083/j.jin2202052 -
JAMA Network Open Jun 2023Reperfusion therapy is the most effective treatment for acute ischemic stroke but remains underused in China. (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Reperfusion therapy is the most effective treatment for acute ischemic stroke but remains underused in China.
OBJECTIVE
To evaluate the effect of a problem-oriented, culturally adapted, targeted quality improvement intervention on reperfusion therapy for patients with acute ischemic stroke in China.
DESIGN, SETTING, AND PARTICIPANTS
In this stepped-wedge cluster randomized clinical trial, patients from 16 secondary and 33 tertiary hospitals in China with acute ischemic stroke within 6 hours of symptom onset were consecutively recruited between July 1, 2018, and June 30, 2020.
INTERVENTIONS
Hospitals were randomly assigned to 1 of 3 sequences to receive the targeted quality improvement intervention (n = 5689), in which workflow reconstruction was promoted to reduce in-hospital reperfusion treatment delays, or usual care (n = 6443), in which conventional stroke care was left to the discretion of the stroke team.
MAIN OUTCOMES AND MEASURES
The primary outcome was the reperfusion therapy rate, a composite outcome of intravenous recombinant tissue plasminogen activator (IV rtPA) or endovascular thrombectomy (EVT) for eligible patients who arrived within 3.5 or 4.5 hours of symptom onset. Secondary outcomes were the IV rtPA administration rate among eligible patients who arrived within 3.5 hours of symptom onset, the EVT rate among eligible participants who arrived within 4.5 hours of symptom onset, the proportion of patients with door-to-needle time within 60 minutes, the proportion of patients with door-to-puncture time within 90 minutes, in-hospital mortality, and 3-month disability as measured by a modified Rankin Scale score greater than 2.
RESULTS
All 12 132 eligible patients (mean [SD] age, 66 [12.1] years; 7759 male [64.0%]) completed the trial. The reperfusion rate was 53.5% (3046 of 5689) for the eligible patients in the intervention period and 43.9% (2830 of 6443) in the control period. No significant improvement in primary outcomes was found for the intervention after adjusting for cluster, period, and imbalanced baseline covariates (adjusted risk difference [ARD], 5.5%; 95% CI, -8.0% to 19.0%; adjusted odds ratio [AOR], 1.26; 95% CI, 0.72-2.21) or for the secondary outcomes. However, significant improvements were found in secondary hospitals for reperfusion therapy (1081 of 1870 patients [57.8%] vs 945 of 2022 patients [42.9%]; ARD, 19.0%; 95% CI, 6.4%-31.6%; AOR, 2.24; 95% CI, 1.29-3.88), IV rtPA administration (1062 of 1826 patients [58.2%] vs 916 of 2170 patients [42.2%]; ARD, 20.3%; 95% CI, 7.4%-33.1%; AOR, 2.37; 95% CI, 1.34-4.19), and EVT (51 of 231 patients [22.1%] vs 37 of 259 patients [14.3%]; ARD, 13.6%; 95% CI, 1.0%-26.3%; AOR, 3.03; 95% CI, 1.11-8.25) in subgroup analyses.
CONCLUSIONS AND RELEVANCE
In this stepped-wedge cluster randomized clinical trial of patients with acute ischemic stroke in China, the use of a targeted quality improvement intervention compared with usual care did not improve the reperfusion therapy rate. However, the intervention may be effective in secondary hospitals.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03578107.
Topics: Humans; Male; Aged; Ischemic Stroke; Tissue Plasminogen Activator; Quality Improvement; Stroke; Reperfusion
PubMed: 37266940
DOI: 10.1001/jamanetworkopen.2023.16465 -
Nature Reviews. Cardiology Mar 2016ST-segment elevation myocardial infarction (STEMI) is most commonly caused by an acute thrombotic occlusion of a coronary artery. For patients in whom the onset of STEMI... (Review)
Review
ST-segment elevation myocardial infarction (STEMI) is most commonly caused by an acute thrombotic occlusion of a coronary artery. For patients in whom the onset of STEMI occurs outside of hospital (outpatient STEMI), early reperfusion therapy with either fibrinolysis or primary percutaneous coronary intervention reduces complications and improves survival, compared with delayed reperfusion. STEMI systems of care are defined as integrated groups of separate entities focused on reperfusion therapy for STEMI, generally including emergency medical services, emergency medicine, cardiology, nursing, and hospital administration. These systems of care have been successful at reducing total ischaemia time and outpatient STEMI mortality. By contrast, much less is known about STEMI that occurs in hospitalized patients (inpatient STEMI), which has unique clinical features and much worse outcomes than outpatient STEMI. Inpatient STEMI is associated with older age, a higher female:male ratio, and more comorbidities than outpatient STEMI. Delays in diagnosis and infrequent use of reperfusion therapy probably also contribute to unfavourable outcomes for inpatient STEMI.
Topics: Delayed Diagnosis; Hospitalization; Humans; Myocardial Infarction; Myocardial Reperfusion; Predictive Value of Tests; Risk Assessment; Risk Factors; Time Factors; Time-to-Treatment; Treatment Outcome
PubMed: 26525542
DOI: 10.1038/nrcardio.2015.165 -
The Journal of Extra-corporeal... Jun 2015Goal-directed therapy is a patient care strategy that has been implemented to improve patient outcomes. The strategy includes aggressive patient management and... (Review)
Review
Goal-directed therapy is a patient care strategy that has been implemented to improve patient outcomes. The strategy includes aggressive patient management and monitoring during a period of critical care. Goal-directed therapy has been adapted to perfusion and has been designated goal-directed perfusion (GDP). Since this is a new concept in perfusion, the purpose of this study is to review goal-directed therapy research in other areas of critical care management and compare that process to improving patient outcomes following cardiopulmonary bypass. Various areas of goaldirected therapy literature were reviewed, including fluid administration, neurologic injury, tissue perfusion, oxygenation, and inflammatory response. Data from these studies was compiled to document improvements in patient outcomes. Goal-directed therapy has been demonstrated to improve patient outcomes when performed within the optimal time frame resulting in decreased complications, reduction in hospital stay, and a decrease in morbidity. Based on the successes in other critical care areas, GDP during cardiopulmonary bypass would be expected to improve outcomes following cardiac surgery.
Topics: Cardiopulmonary Bypass; Delivery of Health Care; History, 20th Century; History, 21st Century; Humans; Myocardial Reperfusion; Treatment Outcome
PubMed: 26405356
DOI: No ID Found