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首页> 外文期刊>Journal of stroke and cerebrovascular diseases: The official journal of National Stroke Association >Characteristics and Outcomes of Patients who Refuse Intravenous Thrombolysis for Acute Ischemic Stroke - The San Diego Experience
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Characteristics and Outcomes of Patients who Refuse Intravenous Thrombolysis for Acute Ischemic Stroke - The San Diego Experience

机译：拒绝急性缺血性卒中静脉溶栓的患者的特征和结果 - 圣地亚哥经验

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Purpose: Intravenous Thrombolysis (IV rt-PA) is administered in <10% of ischemic stroke patients. In rare cases, patients or caregivers refuse IV rt-PA treatment even when recommended by stroke practitioners. We sought to assess the characteristics and outcomes of patients who refuse IV rt-PA for acute ischemic stroke, and to compare outcomes between those who were treated with IV rt-PA and those who refused. Methods: We examined data from the prospectively collected, IRB approved UC San Diego Stroke Registry who presented as a "stroke code" from July 2004 to July 2019 at two academic facilities and five community hospitals. Patients were included if they presented within 4.5 hours of symptom onset or last seen normal, had a "stroke code" alert activated, and were either treated with IV rt-PA or the reason for exclusion was patient/family refusal. Patients were considered "refusers" if IV rt-PA was recommended by the provider during the stroke code and the patient and/or legally authorized representative declined treatment. Baseline demographics, baseline National Institutes of Health Stroke Scale (NIHSS), treatment times and 90-day Modified Rankin Scale (mRS) were collected. Patients who refused IV rt-PA were compared to those that were treated with IV rt-PA. Data was examined for frequencies and distribution. Chi squared was used to evaluate nominal variables. Continuous variables were assessed by Pearson correlation and t test. Kruskal-Wallis or ANOVA were used to evaluate group differences. Results: A total of 1056 patients were included in the analysis. Forty-seven patients (4.5%) refused IV rt-PA. There were no significant socio-demographic differences between patients who were treated with IV rt-PA and those who refused. Compared to patients who were treated with IV rt-PA, patients who refused IV rt-PA had a significantly lower baseline NIHSS (4 vs 9, p < 0.0001) and higher baseline mRS (IQR 0-1.0 vs 0-2.8, p < 0.001). The time from arrival to treatment decision was significantly longer in patients who refused IV rt-PA (group mean 57.9 min vs 48.8 min, p = 0.03). Data for 90-day outcome was available for 556 (55.1%) patients treated with IV rt-PA and 20 (42.5%) patients who refused IV rt-PA. There was no difference in 90-day mRS between groups (p = 0.68). Conclusions: There is a low rate of IV rt-PA refusal in our registry population which is similar to what previous studies have shown. We found that patients who refuse IV rt-PA have significantly milder deficits and significantly worse pre-morbid disability. We speculate that the longer "arrival to decision" time in the refuse IV rt-PA group is due to longer informed consent discussions. This analysis furthers the body of literature regarding rt-PA refusals.
机译：目的：静脉溶栓（IV rt PA）用于<10%的缺血性中风患者。在极少数情况下，患者或护理者即使在中风从业者推荐的情况下也拒绝接受静脉rt-PA治疗。我们试图评估因急性缺血性卒中而拒绝静脉注射rt-PA的患者的特征和预后，并比较接受静脉注射rt-PA和拒绝静脉注射rt-PA的患者的预后。方法：我们检查了预期收集的、经IRB批准的加州大学圣地亚哥分校中风登记处的数据，该登记处于2004年7月至2019年7月在两家学术机构和五家社区医院以“中风代码”的形式呈现。如果患者在症状出现后4.5小时内出现或最后一次出现正常症状，激活了“中风代码”警报，并接受了静脉注射rt-PA治疗，或排除的原因是患者/家庭拒绝，则纳入患者。如果供应商在中风代码期间推荐静脉注射rt-PA，且患者和/或合法授权代表拒绝治疗，则患者被视为“拒绝者”。收集基线人口统计学、基线美国国立卫生研究院卒中量表（NIHSS）、治疗时间和90天改良Rankin量表（mRS）。将拒绝静脉注射rt-PA的患者与接受静脉注射rt-PA的患者进行比较。检查数据的频率和分布。卡方检验用于评估名义变量。连续变量采用皮尔逊相关和t检验进行评估。Kruskal-Wallis或ANOVA用于评估组间差异。结果：共有1056名患者被纳入分析。47名患者（4.5%）拒绝静脉注射rt-PA。接受静脉注射rt-PA治疗的患者与拒绝静脉注射rt-PA的患者之间没有显著的社会人口统计学差异。与接受静脉rt-PA治疗的患者相比，拒绝静脉rt-PA治疗的患者的基线NIHSS显著降低（4比9，p<0.0001），而基线mRS显著升高（IQR 0-1.0比0-2.8，p<0.001）。拒绝静脉注射rt-PA的患者从到达治疗地点到决定治疗的时间明显更长（组平均57.9分钟vs 48.8分钟，p=0.03）。556例（55.1%）接受静脉rt-PA治疗的患者和20例（42.5%）拒绝静脉rt-PA治疗的患者的90天预后数据可用。两组之间的90天mRS无差异（p=0.68）。结论：在我们的登记人群中，静脉注射rt-PA的拒绝率较低，这与之前的研究结果相似。我们发现拒绝静脉注射rt-PA的患者有明显较轻的缺陷和明显更严重的病前残疾。我们推测，拒绝静脉注射rt-PA组的“到达决定”时间更长是因为知情同意讨论的时间更长。这一分析进一步丰富了有关rt-PA拒绝的文献。

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