美国加州大学洛杉矶分校Gregg C. Fonarow联合克利夫兰医学中心Shumei Man团队分析了急性缺血性中风溶栓患者的门诊-扎针时间与1年死亡率及再入院的关系。2020年6月2日，该成果发表在《美国医学会杂志》上。

急性缺血性卒中早期给予静脉内组织型纤溶酶原激活剂（tPA）可降低出院时的死亡率，并显著改善3个月后的功能性结局。但尚不清楚较短的门诊-扎针时间是否可转化为更好的长期结局。

为了探讨急性缺血性卒中患者缩短门诊-静脉tPA扎针时间是否与改善长期预后相关，研究组进行了一项回顾性队列研究，招募2006年1月1日至12月31日，因急性缺血性中风来院就诊的65岁及以上的医保受益人，他们在就诊后4.5小时内接受了静脉tPA治疗。随访至2017年12月31日。主要结局为1年全因死亡率，全因再入院率以及全因死亡或再入院的综合结局。

共有61426名患者在4.5小时内接受tPA治疗，中位年龄为80岁，男性占43.5％。门诊-扎针的中位时间为65分钟。就诊后超过45分钟再接受tPA治疗的48666名患者（79.2％）的全因死亡率为35.0%，全因再入院率为40.8%，全因死亡或再入院率为56.0%，均显著高于就诊后45分钟内接受治疗的患者（分别为30.8%、38.4%和52.1%）。

就诊后超过60分钟再接受tPA治疗的34367名患者（55.9％）的全因死亡率为35.8%，全因再入院率为41.3%，全因死亡或再入院率为56.8%，均显著高于就诊后60分钟内接受治疗的患者（分别为32.1%、39.1%和53.1%）。门诊等待时间每增加15分钟，则与住院后90分钟内全因死亡率增加显著相关，但与90分钟后的全因死亡率不相关；且与全因再入院率、全因死亡或再入院率升高显著相关。

总之，对于65岁及以上急性缺血性中风且接受tPA治疗的患者，缩短门诊-扎针时间可显著降低1年内的全因死亡率和全因再入院率。

附：英文原文

Title: Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke

Author: Shumei Man, Ying Xian, DaJuanicia N. Holmes, Roland A. Matsouaka, Jeffrey L. Saver, Eric E. Smith, Deepak L. Bhatt, Lee H. Schwamm, Gregg C. Fonarow

Issue&Volume: 2020/06/02

Abstract: Importance  Earlier administration of intravenous tissue plasminogen activator (tPA) in acute ischemic stroke is associated with reduced mortality by the time of hospital discharge and better functional outcomes at 3 months. However, it remains unclear whether shorter door-to-needle times translate into better long-term outcomes.

Objective  To examine whether shorter door-to-needle times with intravenous tPA for acute ischemic stroke are associated with improved long-term outcomes.

Design, Setting, and Participants  This retrospective cohort study included Medicare beneficiaries aged 65 years or older who were treated for acute ischemic stroke with intravenous tPA within 4.5 hours from the time they were last known to be well at Get With The Guidelines–Stroke participating hospitals between January 1, 2006, and December 31, 2016, with 1-year follow-up through December 31, 2017.

Exposures  Door-to-needle times for intravenous tPA.

Main Outcomes and Measures  The primary outcomes were 1-year all-cause mortality, all-cause readmission, and the composite of all-cause mortality or readmission.

Results  Among the 61426 patients treated with tPA within 4.5 hours, the median age was 80 years and 43.5% were male. The median door-to-needle time was 65 minutes (interquartile range, 49-88 minutes). The 48666 patients (79.2%) who were treated with tPA and had door-to-needle times of longer than 45 minutes, compared with those treated within 45 minutes, had significantly higher all-cause mortality (35.0% vs 30.8%, respectively; adjusted HR, 1.13 [95% CI, 1.09-1.18]), higher all-cause readmission (40.8% vs 38.4%; adjusted HR, 1.08 [95% CI, 1.05-1.12]), and higher all-cause mortality or readmission (56.0% vs 52.1%; adjusted HR, 1.09 [95% CI, 1.06-1.12]). The 34367 patients (55.9%) who were treated with tPA and had door-to-needle times of longer than 60 minutes, compared with those treated within 60 minutes, had significantly higher all-cause mortality (35.8% vs 32.1%, respectively; adjusted hazard ratio [HR], 1.11 [95% CI, 1.07-1.14]), higher all-cause readmission (41.3% vs 39.1%; adjusted HR, 1.07 [95% CI, 1.04-1.10]), and higher all-cause mortality or readmission (56.8% vs 53.1%; adjusted HR, 1.08 [95% CI, 1.05-1.10]). Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause mortality (adjusted HR, 1.04 [95% CI, 1.02-1.05]) within 90 minutes after hospital arrival, but not after 90 minutes (adjusted HR, 1.01 [95% CI, 0.99-1.03]), higher all-cause readmission (adjusted HR, 1.02; 95% CI, 1.01-1.03), and higher all-cause mortality or readmission (adjusted HR, 1.02 [95% CI, 1.01-1.03]).

Conclusions and Relevance  Among patients aged 65 years or older with acute ischemic stroke who were treated with tissue plasminogen activator, shorter door-to-needle times were associated with lower all-cause mortality and lower all-cause readmission at 1 year. These findings support efforts to shorten time to thrombolytic therapy.

DOI: 10.1001/jama.2020.5697

Source: https://jamanetwork.com/journals/jama/article-abstract/2766633