Jan. 25, 2011-
Since 2003 many hospitals have been focused on achieving recognition as
a certified stroke center, an idea pushed by the Brain Attack Coalition
that envisioned a reduction in deaths from this third leading cause of
death in the U.S. A new study finds the stoke centers are lowering the
stroke death rate, but only modestly.
The study
reported in the January 26 issue of the Journal of the American Medical
Association found patients who had an ischemic stroke and were admitted
to hospitals designated as primary stroke centers had a modestly lower
risk of death at 30 days, compared to patients who were admitted to
non-designated hospitals.
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Stroke is not
only a leading cause of death, it is the leading cause of serious
long-term disability in the United States. Responding to the need for
improvements in acute stroke care, the Brain Attack Coalition (BAC)
published recommendations for the establishment of primary stroke
centers in 2000, and in 2003 the Joint Commission began certifying
stroke centers based on these recommendations, according to background
information in the article.
The Joint
Commission is an independent, not-for-profit organization that accredits
and certifies more than 18,000 health care organizations and programs in
the United States. Joint Commission accreditation and certification is
recognized nationwide as a symbol of quality that reflects an
organization’s commitment to meeting certain performance standards.
Today, nearly
700 of the 5,000 acute care hospitals in the United States are Joint
Commission-certified stroke centers, with some states establishing their
own designation programs using the BAC core criteria. "Despite
widespread support for the stroke center concept, there is limited
empirical evidence demonstrating that admission to a stroke center is
associated with lower mortality," the authors write.
Ying Xian, M.D.,
Ph.D., of the Duke Clinical Research Institute, Durham, N.C., and
colleagues conducted a study to evaluate the association between
admission to stroke centers for acute ischemic stroke and the rate of
death.
Using data from
the New York Statewide Planning and Research Cooperative System, the
researchers compared mortality for patients admitted with acute ischemic
stroke (30,947) between 2005 and 2006 at designated stroke centers and
non-designated hospitals.
Patients were
followed up for mortality for 1 year after hospitalization through 2007.
To assess whether the findings were specific to stroke, the researchers
also compared mortality for patients admitted with gastrointestinal
hemorrhage (39,409) or heart attack (40,024) at designated stroke
centers and non-designated hospitals.
Among the
patients with acute ischemic stroke, 49.4 percent (15,297) were admitted
to designated stroke centers (104) and 50.6 percent to non-designated
hospitals.
The overall
30-day all-cause mortality rate was 10.1 percent for patients admitted
to designated stroke centers and 12.5 percent for patients admitted to
non-designated hospitals.
Analysis
indicated that admission to a designated stroke center hospital was
associated with a 2.5 percent absolute reduction in 30-day all-cause
mortality.
Use of
thrombolytic therapy (dissolving blood clots) was 4.8 percent for
patients admitted at designated stroke centers and 1.7 percent for
patients admitted at non-designated hospitals (adjusted difference in
use, 2.2 percent).
Among patients
surviving to hospital discharge, there was no difference in rates of
30-day all-cause readmission and discharge to a skilled nursing
facility.
"Differences in
mortality also were observed at 1-day, 7-day, and 1-year follow-up. The
outcome differences were specific for stroke, as stroke centers and
non-designated hospitals had similar 30-day all-cause mortality rates
among those with gastrointestinal hemorrhage or acute myocardial
infarction," the authors write.
"Even though the
differences in outcomes between stroke centers and non-designated
hospitals were modest, our study suggests that the implementation and
establishment of a BAC-recommended stroke system of care was associated
with improvement in some outcomes for patients with acute ischemic
stroke."
Editorial:
Preventing Death One Stroke at a Time
In an
accompanying editorial, Mark J. Alberts, M.D., of the Stroke Program,
Northwestern University School of Medicine, Chicago, comments on the
future of acute stroke care.
"A multitiered
system of stroke care is developing, with the comprehensive stroke
center (CSC) at the top of the pyramid, the primary stroke center (PSC)
in the middle, and the acute stroke ready hospital (ASRH) at the base.
“Within a
geographical region, a small number of CSCs would provide care for
patients with the most complicated stroke cases; a larger number of PSCs
would provide care for the patients with typical, uncomplicated cases;
and the ASRH would provide initial screening and triage and begin acute
care for patients in a rural, small urban, or suburban setting.
“Emergency
medical services personnel would perform initial screening and triage
and would transport patients with a clearly defined stroke to the
closest stroke center facility. Using telemedicine technologies,
hospital personnel could communicate and transfer patients to the
facility with the most appropriate level of care. Many states and
guidelines now support and even mandate the diversion of patients
suspected of having a stroke to the nearest stroke center facility."
Top Ten Advances in Stroke Research in 2010
1. “Time
is brain”: Clot-dissolving treatment for acute ischemic stroke found
beneficial in the first 4.5 hours after onset, potentially harmful later
A combined
patient analysis of eight trials of intravenous tissue plasminogen
activator (tPA) for acute ischemic stroke reinforced prior findings of a
strong time-to-treatment effect, with greatest benefit in the first few
hours after onset, and, for the first time, demonstrated increased
mortality from late treatment beyond 4.5 – 6 hours after onset.
· ● Pooled
analysis of the ECASS, ATLANTIS, NINDS and EPITHET trials – Lancet,
May 15, 2010;
www.thelancet.com;
Lancet 2010;375(9727):1695-703; Funding: There was no funding
source for this study.
2.
New mechanism of emboli clearance from the brain vasculature discovered
This study
identified an entirely new way by which brain blood vessels are kept
open by the body in the face of clots – extravasation. Clots that are
not able to be dissolved are sometimes pushed out through blood vessel
walls into the surrounding tissue, restoring nourishing flow in blood
vessels.
· ●
Lam, et al; Nature, May 27,
2010; www.nature.com.
Nature 2010;465:478-482; Funding: No funding sources were listed.
3. Carotid
endarterectomy and carotid artery stenting directly compared
The large
CREST trial compared head-to-head the two
major methods to reopen narrowed carotid arteries carrying blood flow to
the brain: carotid endarterectomy (open surgical repair) and carotid
stenting (endovascular placement of a stent). Overall, both techniques
had similar rates of success and complication, but among younger
patients, under 70 years of age, stenting appeared advantageous while
among older patients endarterectomy appeared advantageous. Those
findings were also supported in a preplanned meta-analysis of individual
patient data from three randomised controlled trials.
· ● CREST – New England Journal,
July 1, 2010;
www.nejm.org; N Engl J Med
2010;363(1):11-23; Funding: National Institute of Neurological
Disorders and Stroke (NINDS).
· ● Carotid Stenting Trialists'
Collaboration – Lancet, Sept. 10, 2010;
www.thelancet.com;Lancet
2010;376:1062-73; Funding: Medical Research Council, the Stroke
Association, Sanofi-Synthélabo, European Union.
4.
Million person milestone, emerging research shows quality initiatives
improve outcomes
In an analysis
of the first one million stroke patients enrolled in the national Get
With the Guidelines® – Stroke quality improvement program at nearly 1400
hospitals across the country, quality of care on 10 performance measures
improved substantially from 2003 to 2009. More than 80 percent of
patients were receiving defect-free care by 2009, up from less than half
in 2003. The Get With The Guidelines database is an invaluable resource
in furthering development of tools and outcomes results that are making
marked improvement in stroke patient care.
· ● Fonarow, et al
– Circulation: Cardiovascular Quality and Outcomes, Feb. 22,
2010;
http://circoutcomes.ahajournals.org;
Circ Cardiovasc Qual Outcomes 2010; 3;291-302.
· ● Smith, et al -
Circulation, Sept. 27, 2010;
http://circ.ahajournals.org;
Circulation. 2010;122:1496-1504.
Funding:
Get With The Guidelines®–Stroke (GWTG-Stroke) is provided by the
American Heart Association/American Stroke Association. The program is
currently supported in part by a charitable contribution from
Bristol-Myers Squib/Sanofi Pharmaceutical Partnership and the American
Heart Association Pharmaceutical Roundtable. GWTG-Stroke has been funded
in the past through support from Boeringher-Ingelheim and Merck.
5. International
study identifies the ten major risk factors for stroke
In the worldwide
INTERSTROKE study, 10 simple risk factors were found to be associated
with 90 percent of the risk of stroke. Targeted interventions that
reduce blood pressure and smoking, and promote physical activity and a
healthy diet, could substantially reduce the worldwide burden of stroke.
· ● INTERSTROKE
Investigators – Lancet, June 18, 2010;
www.thelancet.org; Lancet
2010;376,112-123; Funding: Canadian Institutes of Health Research, Heart
and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer
Cardiovascular Award, Merck, AstraZeneca, Boehringer Ingelheim.
6.
Ultrasound detection of silent emboli identifies patients at high risk
of stroke
This
international, multicenter, prospective study confirms that detection of
silent, microclots traveling to the brain on transcranial Doppler
ultrasound identifies a subgroup of patients with asymptomatic narrowing
of the carotid artery who are at high risk for stroke and might benefit
from surgery or stenting.
· ● ACES –
Lancet Neurology, July 2010;
www.thelancet.com; Lancet
Neurol;9(7):663-71; Funding: British Heart Foundation.
7. Robot-assisted
therapy beneficial for long-term arm impairment after stroke
This randomized
trial suggested that robot-assisted therapy can improve the
rehabilitation of arm function after stroke compared with ordinary care,
though no more than intensive therapist care.
· ● Lo, et al –
New England Journal of Medicine, May 16, 2010;
www.nejm.org; N Engl J Med.
2010;362(19):1772-83; Funding: Veterans Affairs Cooperative Studies
Program and Rehabilitation Research and Development Service.
8. Genetic findings
important in understanding, treating aneurysms
Two new studies
looked at the genetics and treatment of aneurysms, balloon-like
dilations of arterial walls that can be fatal if they rupture or tear.
Saccular intracranial aneurysms are located in the intracranial arterial
wall; their hemorrhage commonly
results in severe neurologic impairment and death.
This
multicenter genome-wide association study in Europe and Japan identified
three new and confirmed two previously-suspected chromosome sites as
harboring genes predisposing to the formation of intracranial aneurysms.
Vascular Ehlers-Danlos syndrome is a rare, genetic, severe disease that
causes arterial dissections and ruptures that can lead to early death.
This randomized trial found that treatment with a beta-blocker
medication to lower mechanical stress on arterial walls prevents
dissection and hemorrrhages in Ehlers-Danlos patients.
· ● Yasuno, et al
– Nature Genetics, May 2010;
www.nature.com; Nat Genet;2010;42(5):420-5;
Funding: Yale Center for Human Genetics and Genomics,Yale Program on
Neurogenetics, US National Institute of Health, Howard Hughes Medical
Institute.
· ● Ong, et al –
Lancet, Sept. 7, 2010;
www.thelancet.com; Lancet.
2010;376;1476 – 1484. Funding: French Ministry of Health, Programme
Hospitalier de Recherche Clinique 2001.
9. Lowering
blood pressure early reduces brain hemorrhage growth
One out of six
strokes is due to bleeding into the brain, intracerebral hemorrhage, a
major cause of death and disability. Two pilot trials found that
aggressively lowering blood pressure, starting within six hours of
stroke onset, is feasible and can reduce hemorrhage expansion. Larger
trials have been launched to determine if this improves patient final
outcome.
· ● ATACH
Investigators – Critical Care Medicine, Feb. 2010;
www.ccmjournal.org; Crit Care
Med. 2010;38(2):637-48; Funding: ?
· ● INTERACT –
Stroke, Dec. 31, 2009; Stroke. 2010;41(2):307-12; Funding:
National Health and Medical Research Council (NHMRC) of Australia.
· ● INTERACT –
Hypertension, Sept. 7, 2010; Hypertension; 2010;56:852-858;
Funding: National Health and Medical Research Council of Australia.
10. Physical
activity, even moderate in degree, reduces stroke risk
A large study
found leisure-time physical activity, even in modest degree, is
associated with lower stroke risk in women. In particular, walking was
generally associated with lower risks of total, ischemic, and
hemorrhagic stroke.
● Sattelmair,
et al – Stroke, April 6, 2010;
http://stroke.ahajournals.org;
Stroke 2010;41(6):1243-50; Funding: National Institutes of
Health.
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