Overall rates at which stroke patients refuse treatment with tissue plasminogen activator (tPA) are low, yet eligible non-Hispanic Black patients are more likely to decline tPA than non-Hispanic White patients.
A new study set out to determine the prevalence of tPA declination in a nationwide registry of acute ischemic stroke (AIS) patients and to investigate differences in declination by race-ethnicity. The results appear in a paper in the February 28 issue of Neurology entitled ‘Race-Ethnic Disparities in Rates of Declination of Thrombolysis for Stroke.’
Ischemic strokes – which occur when a vessel supplying blood to the brain is obstructed by a blood clot -– account for about 87 % of all strokes. The treatment tPA, given intravenously, can dissolve the clot and prevent damage to the brain if given quickly after stroke onset. Earlier regional and single-center studies have found that 4-7% of eligible AIS patients decline intravenous tissue plasminogen activator (tPA).
The American Heart Association/American Stroke Association (AHA/ASA) Get With The Guidelines-Stroke registry was used to identify AIS patients eligible for tPA and admitted to participating hospitals between January 1, 2016 and March 28, 2019. The DCRI serves as the data analysis center for this registry and provided biostatistical expertise for the Neurology paper, which resulted from the study led by the University of Chicago Department of Neurology. Patient demographics and admitting hospital characteristics were compared for tPA-eligible patients who received this therapy and those who declined.
“It would be helpful to better understand how physicians explain the benefits of tPA to stroke patients, to ensure that its potential to help them avoid life-long disability is fully articulated,” said Roland Matsouaka, PhD, study author and DCRI faculty member. “A community-level intervention might be useful in providing information and education, helping to build trust, and addressing any potential biases.”
“Future research will be important to understand the reason for the racial ethnic disparities in stroke patients or their families declining tPA therapy, enabling us to help close the gap for this vulnerable population,” said Ying Xian, MD, PhD, formerly part of the DCRI data analytics team and now Section Head Research, Stroke & Cerebrovascular Diseases, and associate professor at UT Southwestern Medical Center. “One option may be to encourage all institutions to improve the consent process for this life-saving therapy, since it has the highest level of guideline recommendation for stroke.”
Among 177,115 tPA-eligible acute ischemic stroke patients at 1,976 sites, 6,545 patients (3.7%) had tPA declination as the sole documented reason for not receiving this therapy. Patients declining treatment were slightly older, more likely to be female, arrived more often at “off-hours” and earlier after symptom onset. Compared with non-Hispanic Whites, non-Hispanic Black race-ethnicity was independently associated with increased odds of tPA declination, Asian race-ethnicity with decreased odds, and Hispanic ethnicity (any race) with similar odds of tPA declination.
In comparison to patients who did not decline tPA, patients who declined tPA were more often cared for at primary stroke centers, non-teaching hospitals, smaller hospitals (bed size), and hospitals with lower annual tPA administration and stroke patient admission volumes. Hospital characteristics associated with higher odds of tPA declination included being a nonteaching hospital, having a large annual AIS patient volume, having fewer beds, and treating fewer patients with tPA annually.
Other DCRI authors of the paper were Shuaiqi Zhang, PhD; Shreyansh Shah, MD; Barbara L Lytle, BA; and Nicole Solomon, PhD.
Two additional recent papers also examined outcomes in patients with AIS. One, published in the Journal of the American Medical Association (February 10), describes a US retrospective cohort study of 163,038 patients with AIS who were treated with tPA. In these patients, use of non-vitamin K antagonist oral anticoagulants (NOACs) within seven days of hospital arrival was not significantly associated with increased risk of intracranial hemorrhage compared with patients who did not receive NOACs. Duke and DCRI-associated authors of the paper were: Wayneho Kam, MD; DaJuanicia N. Holmes, MS; Adrian F. Hernandez, MD; Roland A. Matsouaka, PhD; and Ying Xian, MD, PhD.
A second paper, published in the January issue of Stroke: Vascular and Interventional Neurology, found that patients within the Get With The Guidelines-Stroke registry not treated with tPA have a high risk of readmission and mortality and high total in-hospital and post-discharge costs. This study included 39,760 patients. Duke and DCRI-related authors were Brian Mac Grory, MB BCh BAO, MRCP; Ying Xian, MD, PhD; Nicole C. Solomon, PhD; and Roland A. Matsouaka, PhD.