Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study

BACKGROUND

Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors.

METHODS

We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay.

RESULTS

In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908).

CONCLUSIONS

Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.

Dual antiplatelet therapy is associated with favorable outcome in acute minor stroke with an onset-to-door time beyond 24 h

BACKGROUND/PURPOSE

In patients with noncardioembolic acute minor ischemic stroke (AMIS), dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel within 24 h after stroke onset was more effective than aspirin alone. This study investigated the efficacy and safety of DAPT in AMIS patients with an onset-to-door time (OTDT) of more than 24 h.

METHODS

This was a retrospective analysis of a prospective stroke registry from 2015 to 2021. Patients with AMIS and an OTDT within seven days were classified into the Early (≤24 h) and Late groups (>24 h) according to the time of antiplatelet administration after stroke onset.

RESULTS

In total, 691 patients were identified. Of these, 446 (64.5%) and 245 (35.5%) patients were classified into the Early and Late groups, respectively. The rates of recurrent infarction and symptomatic intracranial hemorrhage at 90 days were similar between the single antiplatelet therapy (SAPT) and DAPT subgroups in both the Early and Late groups. More patients in the DAPT subgroup had a favorable outcome (modified Rankin scale of 0-1) at 90 days in both Early (84.2% versus 75.0%, p = 0.016) and Late (88.2% versus 76.9%, p = 0.040) groups. DAPT was independently associated with a favorable outcome in both the Early (odds ratio, 1.95; 95% CI, 1.15-3.32; p = 0.013) and Late (odds ratio, 2.72; 95% CI, 1.14-6.48; p = 0.024) groups.

CONCLUSION

In patients with AMIS and an OTDT of more than 24 h, DAPT was associated with a favorable outcome at 90 days.

Association between patient-reported onset-to-door time and mortality in patients hospitalized with COVID-19 disease

INTRODUCTION

Timely hospital presentation and treatment are critical for recovery from coronavirus disease (COVID-19). However, the relationship between symptom onset-to-door time and key clinical outcomes, such as inpatient mortality, has been poorly understood due to the difficulty of retrospectively measuring symptom onset in observational data. This study examines the association between patient-reported symptom onset-to-door time (ODT) and mortality among patients hospitalized and treated for COVID-19 disease.

METHODS

We conducted a retrospective cohort study of emergency department (ED) encounters of patients with COVID-19 disease who were hospitalized and received remdesivir and/or dexamethasone between March 1, 2020, and March 1, 2022. The exposure was patient-reported ODT in days. The outcome of interest was inpatient mortality, including referral to hospice care. We used multivariable logistic regression to examine the association between ODT and mortality while adjusting for patient characteristics, hospital sites, and seasonality. We tested whether severe illness on hospital presentation modified the association between ODT and mortality. Severe illness was defined by Emergency Severity Index triage level 1 or 2 and hypoxia (SpO2 < 94%).

RESULTS

Of the 3451 ED hospitalizations included, 439 (12.7%) resulted in mortality, and 1693 (49.1%) involved patients with severe illness on hospital presentation. Greater ODT was significantly associated with lower odds of inpatient mortality (adjusted odds ratio (AOR) = 0.96, 95% CI = 0.93-1.00, P = 0.023). There was a statistically significant interaction between ODT and severe illness at hospital arrival on mortality, suggesting the negative association between ODT and mortality specifically pertained to patients who were not severely ill upon ED presentation (AOR = 0.93, 95% CI = 0.87-1.00, P = 0.035). The adjusted probability of mortality was significantly lower for non-severely ill, hospitalized patients who presented on days 8-14 (5.2%-3.3%) versus days 0-3 (9.4%-7.5%) after symptom onset.

CONCLUSION

More days between symptom onset and hospital arrival were associated with lower mortality among hospitalized patients treated for COVID-19 disease, particularly if they did not have severe illness at ED presentation. However, onset-to-door time was not associated with mortality among hospitalized patients with severe illness at ED presentation. Collectively, these results suggest that non-severely ill COVID-19 patients who require hospitalization are less likely to decompensate with each passing day without severe illness. These findings may continue to guide clinical care delivery for hospitalized COVID-19 patients.

Assessment of onset-to-door time in acute ischemic stroke and factors associated with delay at a tertiary care center in South India

Objectives

Intravenous thrombolysis is an effective treatment of acute ischemic stroke but has a narrow therapeutic time window of 3-4.5 h. Pre-hospital delay is a major barrier to patients becoming eligible for thrombolysis. This single-center study assessed the factors causing longer onset-to-door (OTD) time to identify measures that will help decrease the delay.

Materials and Methods

Patients with acute ischemic stroke presenting to the emergency department from August to October 2022 were included in the study. The data were collected using a structured questionnaire and was completed by interviewing the patient or the caregivers. Patients were classified as early and late arrivers with the cutoff being 3.5 h. We then analyzed the relationship between early arrival and demographic factors, clinical factors, patient response factors, and logistic factors.

Results

Our study consisted of 153 patients. The average OTD time was 674.33 ± 812.713 min (median: 300; interquartile range: 151-885). The pre-hospital delay was present in 66% of patients. 16.9% of patients came beyond 24 h. In the multivariate analysis, the odds of early arrival were higher among patients who perceived their symptoms as serious (odds ratio [OR]: 18.801; confidence interval [CI]: 3.728-94.803) and lower among patients who experienced a delay in reaching due to traffic (OR: 0.085; CI: 0.008-0.873). Lack of knowledge about stroke centers among both patients and health professionals also contributed to longer OTD times. Out of 52 early arrivers, 24 received thrombolytic therapy after excluding wake-up strokes and contraindications.

Conclusion

Pre-hospital delay continues to stand in the way of patients receiving thrombolysis. Comprehensive stroke education, increasing awareness regarding stroke centers, and promoting ambulance services are some of the interventions which could help tackle the issue.

Impact of living alone on the care and outcomes of patients with ST-elevation myocardial infarction

BACKGROUND

This study aimed to investigate the association between living alone at home and the care and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (pPCI).

METHODS

In total, 557 patients with STEMI underwent pPCI between January 2008 and September 2017. Among them, we included 208 patients who were transferred directly by emergency medical services from their home to the hospital.

RESULTS

Patients were classified into two groups, namely living alone (n = 45) and living with others (n = 163). There were no significant differences in age, sex, and cardiovascular risk factors between the two groups. The onset-to-door (OTD) and onset-to-balloon times were significantly shorter in patients living with others than in those living alone (106.4 vs. 190.8 min, p < 0.01 and 152.3 vs. 236.9 min; p < 0.01, respectively). The left ventricular ejection fraction after pPCI was significantly lower in patients living alone than in those living with others (48.7 % vs. 54.9 %, p < 0.01). Multivariate logistic regression analysis indicated that living alone and the incidence of congestive heart failure were independent predictors of a longer OTD time.

CONCLUSIONS

Patients living alone were less likely to arrive early at the hospital than those living with others. A greater understanding of the inter-relationships among living alone, access to acute cardiac care, and outcomes is essential.

In Hyperacute Recanalization Therapy, Early Hospital Arrival Improves Outcome in Patients with Large Artery Occlusion

BACKGROUND

It is unknown whether the effect of onset---to-door (OTD) time on clinical outcomes differs between -patients with and without large artery occlusion (LAO) who undergo hyperacute recanalization therapy.

METHODS

Hyperacute recanalization therapy includes intravenous thrombolysis tissue-plasminogen activator (tPA), and endovascular therapy (EVT). Favorable clinical outcome was defined as modified Rankin Scale of ≤2 at discharge.

RESULTS

Among 164 patients, 117 (71%) patients received tPA, 86 (52%) received EVT, and 39 (24%) received tPA and EVT. One hundred and fifteen patients (70%) were classified into the LAO group and 49 (30%) into the non-LAO group. In the total cohort, multivariate regression analysis showed OTD time (OR 0.809 [95% CI 0.693-0.944], p = 0.007) was an independent factor related to the favorable outcome. Similarly, among patients with LAO, OTD was an independent negative factor for the favorable outcome (0.779 [0.646-0.940], p = 0.009). On the contrary, OTD was not associated with the favorable outcome (1.5 [0.7-2.5] vs. 1.7 [1.1-3.2], p = 0.155) in patients without LAO. This was confirmed with multivariate regression analysis, which did not show OTD to be an independent factor for the favorable outcome (0.900 [0.656-1.236], p = 0.516).

CONCLUSION

The effect of early hospital arrival on clinical outcome differed between patients with and without LAO.

Delay and its related factors in seeking treatment in patients with acute myocardial infarction

BACKGROUND

Early diagnosis and treatment of myocardial infarction can prevent life-threatening complications such as dysrhythmias and death. The aim of this study was to determine the length of delay and its related factors in seeking treatment among a group of patients with myocardial infarction.

METHODS

In a cross-sectional design, all the patients who had referred to a general teaching hospital (Kashan, Iran) for treatment of myocardial infarction from April 2004 to March 2005 were recruited. Demographic characteristics, the amount of delay, and the causes of having delay were recorded.

RESULTS

Two hundred patients were recruited for this study from which 131 (69%) patients had delay in seeking treatment. Factors such as gender, age, economical status, educational level, referring to a general physician before referring to the hospital, the severity of symptoms, residential place (urban vs. rural), and the time of the onset of the symptoms (day vs. night) were determined to be related to having delay. The most important causes of having delay were: "hoping the symptoms to alleviate spontaneously", "attributing the symptoms to other problems other than heart problems", and "disregarding the symptoms".

CONCLUSION

Regarding the most important causes of having delay in this study, the importance of educating people about the symptoms of myocardial infarction and the importance of early referral to the hospitals is clarified.