Favorable ICH reversal outcomes linked to shorter door-to-treatment time
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Key takeaways:
- Among 5,224 individuals with reversal intervention and documented workflow times, median door-to-treatment time was 82 minutes.
- DTT time of 60 minutes or less was reported in only 27.7% of patient cases.
For individuals with anti-coagulation-associated intracerebral hemorrhage, a door-to-treatment time of 60 minutes or fewer was associated with decreased mortality and discharge to hospice care, according to research from JAMA Neurology.
“Prior clinical trials of coagulopathy reversal have demonstrated a reduction in [intracerebral hemorrhage] expansion and improved clinical outcome,” Kevin N. Sheth, MD, professor of neurology and neurosurgery at the Yale Center for Brain and Mind Health, Yale University School of Medicine, and colleagues wrote. “However, there was not sufficient precision or power to establish the presence of a time-dependent effect.”
Sheth and colleagues aimed to evaluate whether door-to-treatment time (DTT) is associated with favorable outcome in those presenting in hospital with anticoagulation-associated ICH treated with reversal interventions.
Their cohort study analyzed data from the American Heart Association’s Get With The Guidelines–Stroke quality improvement registry. A total of 9,492 individuals with documented reversal intervention status (median age 77 years; 44.6% female) who presented within 24 hours of symptom onset to 465 hospitals across the United States from January 2015 to December 2021 were included. From that initial cohort, 7,469 (78.7%) received reversal therapy, including 4,616 of 5,429 (85%) taking warfarin and 2,856 of 4,069 (70.2%) taking a non–vitamin K antagonist oral anticoagulant.
The primary outcome was inpatient mortality and discharge to hospice, with functional outcome (discharge modified Rankin Scale score, ambulatory status, discharge venue) as a secondary outcome.
DTT times and outcomes, which were analyzed by utilizing logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site.
Among the 5,224 individuals taking a reversal intervention with documented workflow times, results showed the median DTT time was 82 minutes, with a DTT time of 60 minutes or fewer in 1,449 (27.7%) cases.
Researchers additionally found a DTT time of 60 minutes or fewer was associated with decreased mortality and discharge to hospice (adjusted OR = 0.82; 95% CI: 0.69-0.99) but no difference in functional outcome (ie, mRS score of 0 to 3; aOR = 0.91; 95% CI: 0.67-1.24). Factors associated with DTT of 60 minutes or fewer included being white, having higher systolic blood pressure and lower stroke severity.
“Historically, care limitations and therapeutic nihilism characterized this patient population,” Sheth and colleagues wrote. “But the current data ... suggest that patients with anti-coagulation-associated [intracerebral hemorrhage] may be a ripe population for quality improvement initiatives.”