The “Golden Hour” and Acute Brain Ischemia
Presenting Features and Lytic Therapy in >30 000 Patients Arriving Within 60 Minutes of Stroke Onset
Background and Purpose— The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent.
Methods— The Get With the Guidelines–Stroke database was analyzed to characterize ischemic stroke patients arriving at hospital Emergency Departments within 60 minutes of the last known well time from April 1, 2003, to December 30, 2007.
Results— During the 4.75-year study period, among 253 148 ischemic stroke patients arriving directly by ambulance or private vehicle at 905 hospital Emergency Departments, 106 924 (42.2%) had documented, exact last known well times. Onset to door time was ≤60 minutes in 30 220 (28.3%), 61 to 180 minutes in 33 858 (31.7%), and >180 minutes in 42 846 (40.1%). Features most strongly distinguishing the patients arriving at ≤60, 61 to 180, and >180 minutes were greater stroke severity (median National Institutes of Health Stroke Scale score, 8.0 vs 6.0 vs 4.0, P<0.0001) and more frequent arrival by ambulance (79.0%. vs 72.2% vs 55.0%, P<0.0001). Compared with patients arriving at 61 to 180 minute, “golden hour” patients received intravenous thrombolytic therapy more frequently (27.1% vs 12.9%; odds ratio=2.51; 95% CI, 2.41–2.61; P<0.0001), but door-to-needle time was longer (mean, 90.6 vs 76.7 minutes, P<0.0001). A door-to-needle time of ≤60 minutes was achieved in 18.3% of golden hour patients.
Conclusions— At Get With the Guidelines-Stroke hospital Emergency Departments, more than one quarter of patients with documented onset time and at least one eighth of all ischemic stroke patients arrived within 1 hour of onset, where they received thrombolytic therapy more frequently but more slowly than late arrivers. These findings support public health initiates to increase early presentation and shorten door-to-needle times in patients arriving within the golden hour.
- acute care
- acute therapy
- acute stroke
- emergency medical services
- emergency medicine
- stroke care
- stroke delivery
- thrombolytic therapy
The benefit of intravenous (IV) thrombolytic therapy in acute brain ischemia is strongly time dependent. Therapeutic yield is maximal in the first minutes after symptom onset and declines rapidly during the next 4.5 hours.1,2 In the typical large-artery ischemic stroke, for each minute that reperfusion is delayed, 2 million nerve cells die.3 Among every 100 patients treated with IV therapy, for every 10-minute delay in the start of lytic infusion within the 1- to 3-hour treatment window, 1 fewer patient has an improved disability outcome.2 Consequently, patients who present to the hospital within the first 60 minutes of onset have the greatest opportunity to benefit from recanalization therapy. Because of the critical importance of rapid treatment, national recommendations for hospitals that accept acute stroke patients in their Emergency Departments (EDs) are to complete the clinical and imaging evaluation of the patient and initiate lytic therapy within 1 hour of patient arrival.4 The Joint Commission target for primary stroke centers is to achieve a door-to-needle (DTN) time of within 60 minutes in 80% or more of patients.
Originally developed in the setting of trauma treatment, the term the “golden hour” is now a general concept in emergency medicine that is applied to conditions in which hyperacute therapy is more effective than later intervention, including trauma, myocardial ischemia, septic shock, cardiopulmonary resuscitation, and stroke. The frequency, characteristics, and treatment of ischemic stroke patients arriving at hospitals within the golden hour nationally have not previously been well characterized. Several large registry studies in the United States and internationally have provided important information regarding patients within the <3-hour window for lytic therapy.5–9 Of concern, cohort studies have suggested an inverse relation between time from symptom onset to hospital arrival and DTN time among stroke patients treated with IV tissue plasminogen activator (TPA).9 Among patients arriving between 100 and 130 minutes after onset, rapid ED care occurred and DTN times less than or near 60 minutes were often attained, permitting the start of therapy within the 180-minute limit of the drug label. In contrast, among patients arriving early after onset, DTN times were often extended, and therapy was frequently still not administered until nearly the 3-hour mark. The representativeness of these small treatment cohorts is not known.
The Get With the Guidelines(GWTG)-Stroke national dataset offers an opportunity to examine the presenting characteristics of ischemic stroke patients arriving within the golden hour, factors associated with early presentation, the rapidity of lytic care initiation, and the determinants of efficient lytic care in a large, nationally representative cohort.
The American Heart Association and American Stroke Association launched the GWTG-Stroke initiative focused on the redesign of hospital systems of care to improve the quality of care of patients with stroke and transient ischemic attack.10,11 GWTG uses a Web-based patient management tool (Outcome Sciences, Inc, Cambridge, Mass) to collect clinical data on consecutively admitted patients, provide decision support, and enable real-time online reporting features. After an initial pilot phase conducted in 8 states, the GWTG-Stroke program was made available in April 2003 to any hospital in the United States.12 Data from hospitals that joined the program any time between April 2003 and December 2007 were included in this analysis. Each participating hospital received either human research approval to enroll cases without individual patient consent under the common rule or a waiver of authorization and exemption from subsequent review by their institutional review board. Outcome Sciences, Inc, serves as the data collection and coordination center for GWTG. The Duke Clinical Research Institute serves as the data analysis center and has an agreement to analyze the aggregate deidentified data for research purposes.
Case Identification and Data Abstraction
Trained hospital personnel were instructed to ascertain consecutive acute stroke admissions by either prospective clinical identification, retrospective identification according to International Classification of Diseases–9 discharge codes, or a combination. Methods used for prospective identification varied, but they included regular surveillance of ED records (ie, presenting symptoms and chief complaints), ward census logs, and/or neurologic consultations. The eligibility of each acute stroke admission was confirmed at chart review before data abstraction. Patient data abstracted by the patient management tool included demographics, medical history, initial head computed tomography (CT) findings, in-hospital treatment and events, discharge treatment, mortality, and discharge destination. Data on hospital-level characteristics (ie, bed size, academic or nonacademic status, annual volume of stroke discharges, and geographic region) were collected from the American Hospital Association.13
For this study, the GWTG-Stroke database was analyzed to characterize ischemic stroke patients arriving at hospital EDs ≤60 minutes compared with >60 minutes after symptom onset from April 1, 2003, to December, 30, 2007. Patient-level variables were analyzed for all patients meeting the study entry criteria. Hospital-level determinants were analyzed for hospitals that entered ≥5 patients meeting the study criteria in the database. Contingency tables were generated to explore group differences in demographics (age, sex), stroke severity, arrival mode (ambulance, private vehicle), DTN time, door-to-imaging time, and outcome destination at discharge. A χ2 test for nominal data and Kruskal-Wallis tests for ordinal and continuous data were used as tests for unadjusted statistical associations. Statistical significance was defined as P≤0.01. Generalized estimating equations logistic-regression models, accounting for within-hospital clustering, were generated to identify independent predictors of onset-to-door (OTD) time ≤60 minutes and of DTN time ≤60 minutes. General details of the candidate patient and hospital variables and the modeling process have been previously described.10 Statistical significance was defined as P≤0.01. All statistical analyses were performed with SAS version 9.1 software (SAS Institute, Cary, NC).
During the 4.75-year time period, at 905 hospital sites, data for 431 170 ischemic stroke and transient ischemic attack patients were entered into the GWTG-Stroke database. The main analyses of this study were performed for the 106 924 patients in this cohort with ischemic stroke, a documented last known well time (LKWT), and presentation directly to the ED by ambulance or private vehicle. Among excluded patients were 74 671 who did not present directly to the ED (including in-hospital stroke, elective admission directly to the hospital, or secondary transfer from another hospital); 103 351 ED-arriving patients with final diagnoses of transient ischemic attack; and 146 224 direct ED-arriving ischemic stroke patients for whom the LKWT was not documented.
Patient- and hospital-level characteristics among patients with and without a documented LKWT are shown in Table 1. Large differences were noted in arrival by emergency medical services and use of TPA (both higher in documented LKWT patients) and modest differences in other features, including stroke severity (higher in documented LKWT patients) and race (lower frequency of blacks in documented LKWT patients).
Among the direct ED-arriving ischemic stroke patients with a documented LKWT, OTD time was 60 minutes or less in 30 220 (28.3%), 61 to 180 minutes in 33 858 (31.7%), and >180 minutes in 42 846 (40.1%). Among the subgroup who arrived within 60 minutes, mean OTD time was 39.9 minutes (SD, 14.8). In the most recent study year, 2007, among the 809 facilities contributing data, GWTG-Stroke hospitals cared for 10 497 golden hour–arriving ischemic stroke patients.
Table 2 shows patient- and hospital-level characteristics of 3 ischemic stroke time-of-arrival cohorts. All groups were similar in age and sex. In terms of race-ethnicity, patients arriving in ≤1 hour and in 1 to 3 hours, compared with those arriving >3 hours, were slightly more often non-Hispanic whites and less often black or Asian. Among those patients in whom stroke severity was documented (n=51 738), severity was greatest among golden hour–arriving patients (median National Institutes of Health Stroke Scale [NIHSS]score 8), intermediate among 1- to 3-hour–arriving patients (NIHSS score 6), and least among those arriving >3 hours (NIHSS score 4). A similar graded difference was observed in the frequency of arrival at the hospital by ambulance, which occurred in 79.0% of patients arriving in 1 hour or less, in 72.2% of 1- to 3-hour–arriving patients, and in 55.0% of >3-hour–arriving patients. Considering hospital characteristics, arrival within the golden hour occurred mildly more often at hospitals located in the Northeast and West.
Patient and hospital factors independently associated with symptom OTD times ≤1 hour are shown in Table 3. The most powerful characteristics independently associated with increased odds of early arrival were severe neurologic deficit, arrival by ambulance rather than private transport, and atrial fibrillation. Patient factors associated with decreased odds of arrival in the golden hour included older age, female sex, and atherosclerotic risk factors (hypertension, tobacco use, and diabetes). Hospital factors associated with decreasing odds of golden hour arrival included hospital location in the South (US Census region definition) and higher annual number of stroke admissions.
During the study period, IV TPA was administered in 12 545 ischemic stroke patients of the study cohort. (In addition, TPA was administered to 159 direct ED-arriving patients who received a final diagnosis of transient ischemic attack.) The 12 545 TPA-treated ischemic stroke patients represented 11.8% of all direct ED-arriving ischemic stroke patients with documented LKWTs and 5.0% of all direct ED-arriving ischemic stroke patients. Among the ischemic stroke patients receiving IV TPA, 8111 (64.7%) arrived at hospital within the first 60 minutes, 4327 (34.5%) between 61 and 180 minutes, and 107 (0.9%) >180 minutes. Compared with 61- to 180-minute arrivers, patients arriving in the first 60 minutes received IV thrombolytic therapy more frequently (27.1% vs 12.9%, unadjusted odds ratio=2.51; 95% CI, 2.41 to 2.61, P<0.0001).
The mean DTN time across all IV TPA–treated patients was 86 minutes (SD, 41.6). An inverse relation between OTD time and DTN time was noted, with a correlation coefficient of −0.30 (Figure 1). DTN time was longer among patients arriving in the first hour then in patients arriving in hours 1 to 3 (mean, 90.6 vs 76.7 minutes, P<0.0001). The distribution of DTN times in ≤1 hour–arriving patients is shown in Figure 2. Total mean elapsed time from symptom onset to treatment in patients arriving within the first hour was 129 minutes (SD, 39). Among these early-arrival patients, 1.6% received TPA within 60 minutes of onset, 11.0% between 61 and 90 minutes, 30.2% between 91 and 120 minutes, 31.5% between 121 and 150 minutes, 21.7% between 151 and 180 minutes, and 4.0% later than 180 minutes.
The target DTN time of ≤60 minutes was achieved in 18.3% of golden hour–arriving patients. Patient characteristics in the DTN ≤60-minute and >60-minute groups among the golden hour–arriving cohort are shown in Table 4. DTN ≤60-minute patients were slightly younger and more often male compared with >60-minute patients. In contrast, stroke deficit severity, ambulance mode of ED arrival, and race did not differ among the DTN ≤60-minute and >60-minute patients. The proportion of patients with a DTN time of ≤60 minutes increased modestly over time, from 12.8% in 2003 to 19.5% in 2007, with a trend showing an increase of 1.2% per year. In contrast, there was no relation of achievement of DTN ≤60 minutes to the duration of hospital participation in the GWTG-Stroke Program. The proportion of patients with DTN ≤60 minutes nominally increased from 18.2% in year 1 to 18.9% in year 5 of GWTG-Stroke participation, with a correlation coefficient of 0.11 (P=0.65).
Among the 905 hospitals enrolling any patient in the database during the study time period, 473 entered 5 or more patients who arrived directly to the ED with an OTD time of ≤60 minutes. Among these hospitals, the proportion of golden hour patients with a DTN time of ≤60 minutes was 0% to 20% at 307 hospitals (64.9%), 21% to 40% at 132 (27.9%), 41% to 60% at 30 (6.3%), 61% to 80% at 4 (0.8%), and 81% to 100% at none. After dividing hospitals into quartiles, at the 121 hospitals with the highest proportion of golden hour patients with DTN times of ≤60 minutes, the proportion of golden hour–arriving patients treated within the first hour after arrival ranged from 27% to 80%; in the 116 hospitals of the second-quartile hospital group, the proportion ranged from 15% to 27%; in the 118 hospitals of the third quartile, the proportion ranged from 3% to 14%; and in the 118 hospitals of the bottom quartile, the proportion ranged from 0% to 2%. Table 5 shows the characteristics of the hospitals among these different performance groups. A higher number of patients treated with IV TPA annually was the only hospital characteristic associated with a higher proportion of golden hour patients treated within 60 minutes of arrival. Variables that were not predictive included hospital size, total number of stroke patients encountered, academic or nonacademic status, months of participation in the GWTG-Stroke program, and geographic region.
Results of multivariate modeling identifying patient- and hospital-level factors independently associated with DTN times of ≤60 minutes among golden hour–arriving patients are shown in Table 6. Greater stroke severity increased the odds of the start of lytic treatment within 1 hour of arrival, whereas older age, female sex, and history of diabetes or prior stroke/transient ischemic attack decreased the odds.
There have been several important national and multicenter registry studies of early-arriving stroke patients,5–9 but this study is the largest and the first to characterize in detail ischemic stroke patients who arrive at hospital within the first 60 minutes after onset, the golden hour when the opportunity to save threatened brain tissue by reperfusion is greatest. The sheer size of the golden hour–arriving population is a notable finding of the investigation. Patients arriving in the first hour of onset accounted for >1 in 4 ischemic stroke patients who presented to GWTG-Stroke hospitals with documented LKWTs and at least 1 in 8 of all ED-arriving ischemic stroke patients. From recent estimates for the annual incidence of ischemic stroke in the United States and the proportion of ischemic patients admitted to hospital, from these findings it may be projected that >55 000 Americans each year present to acute care hospitals within the first 60 minutes of onset of ischemic stroke.
Because early time of presentation is critical to early start of therapy, a public health priority is to increase even further the proportion of acute ischemic stroke patients presenting within the first 60 minutes after onset.7 In the GWTG-Stroke dataset, the 2 most powerful determinants of arrival in the first 60 minutes were greater severity of stroke deficits on the NIHSS and arrival by ambulance rather than private vehicle. These findings suggest that public health messages have a substantial opportunity to increase the proportion of early-arriving patients by educating patients, family members, and on-scene bystanders to recognize the symptoms of stroke and to react to less severe as well as more severe deficits by calling 911 and activating the emergency medical system. Another factor affecting arrival in the first hour was race-ethnicity, with blacks and Asians less likely to arrive in the golden hour than non-Hispanic whites. In a recent study in 13 states and the District of Columbia, awareness of stroke warning symptoms and the importance of activating the 911 system was less common among black, Hispanic, and other (predominantly Asian) race-ethnic groups than among whites.14 Several studies have found that white, non-Hispanic patients with stroke are more likely to arrive at the ED in early time windows and to receive thrombolytic therapy than are blacks and other race-ethnic groups.15,16 These findings suggest a need not only for general public education campaigns but also for campaigns targeted to distinctive communities, including blacks, Hispanics, and Asians. Educational campaigns have greater effectiveness when they are tailored to an individual’s cultural heritage.17 Targeted campaigns for stroke awareness would be beneficial, by building on the foundation of past and current initiatives, including the American Stroke Association Power to End Stroke campaign, the Beauty Shop Stroke Education Project, “Hip-Hop Stroke,” and the Kids Identifying and Defeating Stroke.
Patients who arrived at the ED within the first 60 minutes had a 2.5-fold higher rate of treatment with IV fibrinolytic therapy than did patients arriving at 61 to 180 minutes, with >1 in 4 golden hour–arriving patients receiving IV TPA. Prior studies have indicated that, were all ischemic stroke patients to arrive immediately at hospital after onset, about one quarter would be appropriate candidates for IV recanalization therapy, whereas three quarters would have other contraindications to therapy, such as having mild strokes, abnormal coagulation studies, or recent surgery.18,19 Accordingly, it appears that GWTG-Stroke hospitals successfully delivered IV fibrinolytic therapy to the great preponderance of patients arriving in the golden hour who were fully eligible for therapy.
However, although the proportion of golden-hour patients treated with fibrinolytic therapy was substantial, the speed of initiation of treatment after hospital arrival was often below the recommended national target of a DTN time of ≤60 minutes. As in prior smaller studies,9 an inverse relation was noted between time of hospital arrival and DTN time in IV TPA–treated stroke patients. Among patients arriving 100 to 130 minutes after onset, rapid ED care often occurred, and DTN times <60 minutes were frequently achieved, permitting the start of therapy within 180 minutes. However, among patients arriving earlier, DTN times were often extended. The shorter DTN times in later-arriving patients in part likely reflect a selection effect. Patients in whom the responding team was unable to start therapy before the 3-hour mark had elapsed did not receive treatment and therefore were not entered into analyses of the interval from arrival to therapy start. However, this shorter treatment time also likely reflects a systematically more rapid diagnostic and therapeutic response by hospital stroke teams in later-arriving patients, when the time remaining to start therapy within the 3-hour limit was limited. The average DTN time to therapy start in golden hour–arriving patients was >1.5 hours, and <1 in 5 patients had a DTN time meeting the national target of <60 minutes.
It is important to emphasize that the national <60-minute DTN target was somewhat arbitrarily chosen, based on the opinion of a small group of experts of what was safely achievable rather than formal time-motion studies or large-scale practice experience.4 Multiple studies have found that the target is achieved in only a minority of patients, even in very experienced centers. It is perhaps currently best viewed as an ambitious target that centers should, over time, steadily approach, rather than a minimum target that all centers should currently meet.
Nonetheless, this study identifies substantial opportunities nationally for improvement in the speed of fibrinolytic therapy initiation in acute ischemic stroke patients. Once patients with ischemic stroke have done their part by arriving at a medical center early, it is incumbent on the receiving hospital to perform rapid diagnostic evaluation and, in appropriate patients, swiftly initiate IV fibrinolytic therapy. In golden hour–arriving patients, there are natural human tendencies to use the additional time available before the outermost permitted treatment time (such as 3 or 4.5 hours) to increase diagnostic certainty and treatment consensus. Health professionals are naturally tempted to use this time to elicit the history in greater detail, perform a fuller neurologic physical examination, carry out a detailed review of imaging and laboratory tests, discuss more fully the benefits and risks of therapy with patients and on-scene family, and reach primary care physicians and other off-scene advisors to arrive at a comfortable, consensus treatment decision. Although there are many valid reasons to delay the start of therapy in early-arriving patients, they are all trumped by the 1, overwhelming reason to hurry—the brain is dying all the while that these activities are taking place.
The need to emphasize the DTN time target, rather than a treat-before-final-time window expiration approach, has been further increased by the recent demonstration that IV TPA can confer some modest benefit up to 4.5 hours of onset, with resulting expansion of the treatment window according to European, Canadian, and US national guidelines.20–22 Without the looming hard cutoff of the old 3-hour limit, patients now arriving at hospital in the second hour after onset may be at risk for the slower response and initiation of IV TPA observed in this study for golden-hour patients.
System interventions focused on continuous, iterative quality improvement can reduce DTN times for ischemic stroke patients. In the 2 National Institute of Neurological Disorders and Stroke–TPA trials themselves, the median DTN time was 64 minutes, even though extensive research informed consents had to be obtained in all patients.23 In regular clinical practice, select centers worldwide have reported mean DTN times well <60 minutes, including 25 minutes in Erlangen, Germany (M. Kohrmann and P. Schellinger, personal communication, 2010); 29 minutes in Busan, Korea24; and 38 minutes in Bergen, Norway.25 Successful centers report that effective components of programs to accelerate DTN times include prearrival notification by emergency medical service providers; written protocols for acute triage and patient flow; single call systems to activate all stroke team members; CT or magnetic resonance scanner clearance as soon as the center is made aware of an incoming patient; storage and rapid access to lytic drugs in the ED; collaboration in developing treatment pathways among physicians, nurses, pharmacists, and technologists from Emergency Medicine, Neurology, and Radiology Departments; and continuous data collection to drive iterative system improvement24–26 (M. Kohrmann and P. Schellinger, personal communication, 2010).
Encouraging in our study were observations that achievement of DTN times <60 minutes was highest at hospitals with a larger volume of IV TPA experience and a mild temporal improving trend from 2003 to 2007. The number of hospitals with large volume experience is likely to increase in coming years owing to several factors, including the increase to 4.5 hours in the time window for IV TPA, regionalization of emergency stroke care with direct routing of patients to state-designated stroke centers,27 and the emergence into practice of a generation of treatment-oriented neurologists and emergency physicians. The finding that the length of time in the GWTG-Stroke program was not associated with an increase in the proportion of patients treated within 60 minutes of arrival suggests a need to revisit and reframe aspects of the GWTG-Stroke toolkit and intervention strategy to highlight the importance of this target and provide concrete strategies for its achievement in various practice settings.
This study has several limitations. Hospitals participating in GWTG-Stroke are likely to have more well-organized stroke systems of care than do nonparticipating hospitals, so other US hospitals are likely, on average, to have worse lytic treatment rates and DTN times than observed in this cohort. Nonetheless, by the final year of observation, ≈23% of US hospitals containing ≈41% of licensed US hospital beds were participating in GWTG-Stroke, so this study does reflect a substantial proportion of US practice. The LKWT was documented in 42% of patients. Although this rate is higher than in many epidemiologic studies (in which LKWT is often documented only 15% to 30% of the time), it is lower than desirable. However, is likely that the LKWT is more often documented among early-arriving patients, in whom it greatly influences ED management, and less often documented among late-arriving patients, in whom the exact onset time is of less practical importance. In accord with this hypothesis, patients with documented LKWTs more often arrived by emergency medical service ambulance and had greater stroke severity, 2 features associated with earlier arrival. Consequently, the analyses in this study confined to the golden hour–arriving patients likely capture the great preponderance of actual golden hour–arriving patients in the study period. During the study period, a small group of treated patients received a final diagnosis of transient ischemic attack, accounting for 1.3% of IV TPA–treated patients. It may be suggested that the diagnosis in these patients should be reclassified as therapeutically averted strokes and included in the ischemic stroke group. We retained the original GWTG-Stroke database diagnostic categories, so our time to treatment analysis was performed in the 98.7% of IV TPA–treated patients who received a final diagnosis of ischemic stroke. Residual measured and unmeasured confounding variables may have influenced some of the findings.
We investigated the influence of multiple patient- and hospital-level factors on care of early-arriving patients. However, many additional factors important in fostering rapid care were not captured in the GWTG-Stroke database and therefore not analyzed, including pre-arrival notification policies of local emergency medical service agencies, hospital provision of education programs to emergency medical services, existence of a regional stroke system of care with routing of stroke patients directly to designated stroke centers, location of CT or magnetic resonance imaging scanners in the ED, and policies regarding need for ancillary testing before treatment, such as coagulation studies, CT angiography, and CT perfusion imaging or multimodal magnetic resonance imaging. Data quality is always a concern in registry studies, and the GWTG-Stroke registry is implemented by a diverse group of users. To optimize data quality, the GWTG-Stroke program includes detailed training of site chart abstractors, standardized case definitions and coding instructions, predefined logic and range checks on data fields at data entry, audit trails, and regular data quality reports for all sites. Limited source documentation audits at the individual state and site level have shown high data quality, and a nationally representative audit is under way. Nevertheless, as in any cardiovascular and stroke registry, data are subject to limitations in the quality and accuracy of the medical records themselves, as well as to the quality of medical record abstraction. Furthermore, there is a portion of ischemic stroke patients for whom onset time is unavailable, not due to limitations in data quality but because the time of onset cannot be obtained from the patient.
We conclude that golden hour–arriving patients are a substantial population, accounting for at least 1 in 8 ischemic stroke patients who arrive directly to the ED. Arrival by ambulance rather than private vehicle was among the most powerful determinants of arrival in the golden hour. On arrival, they receive thrombolytic therapy more frequently and earlier than do late arrivers. Although target DTN times ≤60 minutes are achieved in fewer than one fifth of golden hour–arriving patients, treatment times show a mild improving national trend over time and are better at high treatment volume centers. These findings support sustained public education efforts to increase the proportion of patients arriving within the first 30 to 60 minutes after stroke onset by emphasizing the recognition of stroke symptoms and the immediate activation of 911. These data also encourage reinvigorated hospital performance improvement activities to shorten DTN times in patients who present in the golden hour, when the volume of salvageable brain and the patient’s capacity to benefit from reperfusion therapy are greatest.
Sources of Funding
GWTG-Stroke is funded by the American Heart Association and the American Stroke Association. The program is also supported in part by unrestricted educational grants to the American Heart Association by Pfizer, Inc, New York, NY, and the Merck-Schering Plough Partnership (North Wales, Pa), who did not participate in the design, analysis, manuscript preparation, or approval. J.L.S. was supported for this work by an American Heart Association PRT Outcomes Research Center Award and by NIH-NINDS Awards P50 NS044378 and U01 NS 44364.
Dr Saver serves as a member of the GWTG Science Subcommittee and as a scientific consultant regarding trial design and conduct to CoAxia, Concentric Medical, Talecris, and Ev3 (all modest); received lecture honoraria from Ferrer and Boehringer Ingelheim (modest); was an unpaid investigator in a multicenter prevention trial sponsored by Boehringer Ingelheim; has declined consulting/honoraria monies from Genentech since 2002; and is an employee of the University of California, which holds a patent on retriever devices for stroke. Dr Smith receives research support from the NIH (NINDS R01 NS062028), the Canadian Stroke Network, the Hotchkiss Brain Institute, and Canadian Institutes for Health Research and receives salary support from the Canadian Institutes for Health Research. Dr Fonarow receives research support from the NIH (significant); serves as a consultant to Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis (all modest); receives speaker honoraria from Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis (all significant); and is an employee of the University of California, which holds a patent on retriever devices for stroke. Dr Reeves receives salary support from the Michigan Stroke Registry. Dr Zhao is a member of the Duke Clinical Research Institute, which serves as the American Heart Association GWTG data coordinating center. Dr Olson is a member of the Duke Clinical Research Institute, which serves as the American Heart Association GWTG data coordinating center. Dr Schwamm serves as a consultant to the Research Triangle Institute, CryoCath, and the Massachusetts Department of Public Health.
- Received March 6, 2010.
- Revision received March 12, 2010.
- Accepted March 17, 2010.
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