作者：Susan Jeffrey
出處：WebMD醫學新聞
October 1, 2009 — 一項新的觀察性研究結果發現，2001年和2004年，症狀發生2小時內到達的病患數目沒有差異，但2004年時接受血栓溶解治療的人數逐漸增加。
由來自康乃狄克州紐哈芬市耶魯大學醫學院Judith H. Lichtman醫師的結論是，這個數字的增加代表醫院照護在這段時間系統面上的提升。然而，症狀發生後立即住院人數持平，代表公共衛生的觀點仍然有努力空間，必須讓病患早點就診。
Lichtman醫師向Medscape神經學表示，這提起了一個中風照護中最大的挑戰，就是協助人們儘快認知中風發生，並且儘快尋求醫療協助。這激勵我們的是，如果將這分成兩個部份來看，讓病患就診，之後治療，確實看來我們似乎正在改善病患的治療。我只是覺得我們還有進步的空間。
研究報告發表於10月1日線上版中風（Stroke）期刊。
【標竿計劃】
為了這項研究，Lichtman醫師與其同事們擷取參與缺血性中風標竿計劃健康系統大學社團教學中心，症狀發生48小時內到達急診且住院的連續缺血性中風病患。他們針對兩個時間點進行研究：2001年1月1日到3月31日（35家中心）以及2004年1月1日到6月30日（32個中心）。
Lichtman醫師表示，研究者們比較症狀發生2小時內到達以及2小時後到達病患的流行病學資料與臨床特徵。此時，使用靜脈注射組織胞漿素原活化劑（IV-tPA）的黃金時間為3小時，儘管這個時間已經被延長到4.5小時，但2個小時可能是在3個小時截止時間前進行完整檢查的閾值。
整體來說，研究者們收集到2001年時的428位病患資料，以及2004年時的481位病患資料。2001年與2004年之間，於症狀發生2小時內到達醫院的病患數目並沒有顯著差異，但是接受IV-tPA的病患數目顯著較高。
【2001年與2004年，在症狀發生2小時內接受IV-tPA的病患比例】
試驗終點 | 2001 | 2004 | P |
症狀發生 2 小時內到達醫院（ % ） | 37 | 38 | .63 |
以 IV-tPA 治療的比例（ % ）
| 14.0 | 37.5 | .0001 |
Lichtman醫師表示，在風險校正分析中，作者們發現黑人病患在症狀發生2小時內到達醫院的勝算較低。這也是一個重要發現，因為這顯示我們的中風病患族群可能有個特定的分層，他們的中風症狀可能因為某些因素而沒有出現的那麼快。
或許不令人意外的，以維克福里斯特中風嚴重度定義的嚴重中風，比較可能在症狀發生2小時內到達。
【與快點到達醫院有關的因素】
因素 | 勝算比 | 95% 信賴區間 |
黑人 | 0.55 | 0.39 – 0.78 |
嚴重中風 | 2.17 | 1.49 – 3.15 |
她附帶表示，有些非常好的美國心臟醫學會大眾知識陣營活動正在進行中，所以在未來決定這些活動是否有效來再次評估我們的進展，將會是有趣的。
在他們進行這些研究時，症狀發生超過3小時並不建議投予tPA。從那時候起，治療的黃金時間已經被延長到4.5個小時。
在這組數據中，Lichtman醫師與其同事們確實將時間延長到症狀發生後3.5小時，來看多少比例的病患到達醫院。她指出，我們看到大約三分之一的病患在治療黃金時間內到達醫院，在延長的時間內，仍只有不到一半的病患到達醫院。我認為，我們在降低中風病患延遲尋求照護上，仍是個很大的公共衛生課題。
Lichtman醫師接受疾病控制與預防中心的經費贊助。作者們表示已無相關資金上的往來。
More Patients Arriving Within 2 Hours of Ischemic Stroke Are Receiving TPA
By Susan Jeffrey
Medscape Medical News
October 1, 2009 — A new observational study finds that although no more stroke patients arrived at the hospital within 2 hours of symptom onset in 2001 than in 2004, more of those who did arrive received thrombolytic therapy at the later time point.
The increase suggests system-level improvements in hospital care during that period, the researchers, led by Judith H. Lichtman, MD, from Yale University School of Medicine, New Haven, Connecticut, conclude. However, the flat number of patients admitted promptly after symptom onset suggests more work is needed from a public health perspective to get patients in the door.
"This again raises the issue that one of the biggest challenges in stroke care is to help people promptly recognize a stroke and seek medical care as soon as possible," Dr. Lichtman told Medscape Neurology. "What's encouraging here, if we look at it from a 2-part approach of getting people in and then treating, it does look like we're shifting toward improvements for patients in terms of treatment. I just think we still have room for improvement."
Their report was published online October 1 and will appear in the December issue of Stroke.
Benchmarking Project
For this study, Dr. Lichtman and colleagues abstracted data on consecutive ischemic stroke patients admitted to hospital from the emergency department within 48 hours of symptom onset at academic centers participating in the University HealthSystem Consortium Ischemic Stroke Benchmarking Project. They looked at 2 periods of time: January 1 to March 31, 2001 (35 centers), and January 1 to June 30, 2004 (32 centers).
The researchers compared demographics and clinical characteristics of patients arriving within 2 hours of symptom onset, and after 2 hours. At this time, the time window for use of intravenous tissue plasminogen activator (IV-tPA) was 3 hours, although it has since been expanded to 4.5 hours, Dr. Lichtman noted. Two hours was the threshold of arrival that might allow a full work-up before the deadline at 3 hours.
In all, the researchers had data on 428 patients seen in 2001 and 481 from 2004. There was no significant difference in the number of patients who arrived in the 2-hour window between 2001 and 2004, but significantly more patients received treatment with IV-tPA.
Percentage of Patients Arriving Within 2 Hours of Symptom Onset and Receiving IV-tPA in 2001 and 2004
| Endpoint | 2001 | 2004 | P |
| Hospital arrival within 2 hours of symptom onset (%) | 37 | 38 | .63 |
| Treatment with IV-tPA (%) | 14.0 | 37.5 | .0001 |
In risk-adjusted analysis, the authors found black patients had lower odds of arriving within 2 hours of symptom onset. "That's an important finding as well, because it's showing us there may be a particular segment of our stroke population who for some reason are not acting quickly on their stroke symptoms," Dr. Lichtman noted.
Perhaps not surprisingly, those with severe strokes as defined by the Wake Forest Stroke Severity Scale were more likely to arrive within 2 hours.
Factors Associated With Prompt Arrival at the Hospital
| Factor | Odds Ratio | 95% CI |
| Black race | 0.55 | 0.39 – 0.78 |
| Severe stroke | 2.17 | 1.49 – 3.15 |
"There are some wonderful American Heart Association public awareness campaigns that are in place now, so it would be interesting to assess our progress again in the future to determine whether or not these campaigns are working effectively," she added.
At the time they performed the study, 3 hours after symptom onset was the threshold after which it was not recommended to give tPA, she noted. Since that time, the time window within which treatment can be given has been expanded to 4.5 hours.
In this data set, Dr. Lichtman and colleagues did look out to 3.5 hours after symptom onset to see what proportion of patients arrived at the hospital. "We see that instead of about a third of patients arriving within the treatment window, it was still under a half of patients in the expanded time frame," she said. "I still think we have a big public health issue to reduce care-seeking delays for stroke patients."
Dr. Lichtman is supported by a grant from the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.
