Long term prognosis in ischemic stroke patients treated with intravenous thrombolytic therapy

Uvod: Primena trombolitičke terapije je povezana sa boljim funkcionalnim oporavkom tri meseca nakon akutnog ishemijkog moždanog udara (AIMU), ali ostaje nejasno da li ima uticaj na preživljavanje i održavanje povoljnog efekta na funkcionalni oporavak tokom dužeg perioda praćenja. Cilj ovog istraživanja je bio da se proceni da li se povoljan efekat trombolitičke terapije na ishod održava godinu dana i više nakon moždanog udara. Metodologija: U ovoj kohortnoj studiji sa kontrolnom grupom ukupno je analizirano 259 tromboliziranih i 259 netromboliziranih bolesnika (uparenih prema polu, starosti i težini neurološkog deficita) koji su lečeni u periodu od februara 2006. godine do januara 2013. godine, u Jedinici za moždani udar Odeljenja urgentne neurologije Klinike za neurologiju. Rezultati: Vreme praćenja bolesnika od indeksnog AIMU je bilo do sedam godina, uz napomenu da je polovina bolesnika ispitivana minimum tri godine od primene trombolitičke terapije. Nakon perioda praćenja, nije bilo razlike u preživljavanju između dve grupe ispitanika: 56 (21,6%) bolesnika u grupi tromboliziranih je preminulo, naspram 62 (23,9%) u grupi netromboliziranih (Log Rank 0,240, p=0,624). Trombolitička terapija nije imala bitan efekat na preživljavanje bolesnika uprkos povećanom riziku od simptomatske intracerebralne hemoragije. Približno je svaki peti bolesnik preminuo u obe analizirane grupe tokom vremena praćenja. Godine starosti, težina neurološkog deficita, pojava sICH, ranog neurološkog pogoršanja, prethodna upotreba antiagregacione terapije, nepoznat uzrok AIMU i pojava medicinskih komplikacija tokom hospitalizacije su bili prediktori ranog letaliteta (u prvih 30 dana od nastanka AIMU). Godine starosti iznad 70 godina, težak neurološki deficit (NIHSS skor 15 i iznad), dijabetes melitus, atrijalna fibrilacija, medicinske komplikacije tokom hospitalizacije su bili prediktori dugoročnog mortaliteta. Odličan funkionalni oporavak tri meseca nakon AIMU bio povezan sa smanjenim rizikom od umiranja tokom perioda praćenja. Ključni rezultat ovog istraživanja je da se povoljan efekat trombolitičke terapije na funkcionalni oporavak održavao i nakon medijane vremena praćenja od tri godine od inicijalnog AIMU. Tako je odličan funkcionalni oporavak nakon perioda praćenja imalo oko 55% bolesnika u grupi tromboliziranih, naspram 43% u grupi netromboliziranih bolesnika (HR 1,64; 95% CI 1,16-2,32)...Background and Purpose: It remains unclear whether intravenous thrombolytic treatment with recombinant tissue plasminogen activator has an impact on the survival and maintenance of a favorable effect on functional recovery over a longer follow-up period. The aim of this study was to assess whether thrombolytic treatment has a favorable effect on functional recovery and survival more than one year after the stroke. Methods: This matched cohort study included 259 patients with acute IS treated with thrombolytic treatment plus standard care and 259 patients treated with standard care alone in the Stroke Unit in period from February 2006 to January 2013. Results: After the median follow-up period of 3 years (range 1 to 7 years), survival did not differ significantly between groups: 56 (21.6%) patients in thrombolyzed group versus 62 (23.94%) patients in non- thrombolyzed group died (Log Rank 0.240, p=0.624). In multivariate Cox proportional-hazards regression model older age, stroke severity, prior use of antiplatelet, occurrence of symptomatic ICH and medical complications during hospitalization were independent predictors of short term (30 days) mortality after stroke. In multivariate Cox proportional-hazards regression model older age (more than 70 years old), stroke severity (NIHSS≥15), history of diabetes mellitus and atrial fibrillation were independent predictors of long term mortality after stroke, while the excellent functional recovery three months after stroke was associated with a reduced risk of dying during the follow-up period. After follow- up period, 55% patients in IVT treated group versus 43% patients in control group had an excellent outcome- modified Rankin score 0-1 (HR 1.64, 95% CI 1.16-2.32). In multivariate Cox proportional-hazards regression model IVT treatment and decrease in NIHSS score in the first 24 h after treatment (8 point decrement or NIHSS 0) were positive predictors of an excellent stroke outcome . Adding the excellent three-month recovery in the multivariate model, this variable becomes the only strong predictor of outcome, HR 11.27; 95% CI 6.45-19.63; p<0.001. Medication persistence was higher among IVT- treated patients compared to non- IVT- treated patients. After adjustment for possible variables IVT was independent predictor of returning to full time job..

Long term prognosis in ischemic stroke patients treated with intravenous thrombolytic therapy

Uvod: Primena trombolitičke terapije je povezana sa boljim funkcionalnim oporavkom tri meseca nakon akutnog ishemijkog moždanog udara (AIMU), ali ostaje nejasno da li ima uticaj na preživljavanje i održavanje povoljnog efekta na funkcionalni oporavak tokom dužeg perioda praćenja. Cilj ovog istraživanja je bio da se proceni da li se povoljan efekat trombolitičke terapije na ishod održava godinu dana i više nakon moždanog udara. Metodologija: U ovoj kohortnoj studiji sa kontrolnom grupom ukupno je analizirano 259 tromboliziranih i 259 netromboliziranih bolesnika (uparenih prema polu, starosti i težini neurološkog deficita) koji su lečeni u periodu od februara 2006. godine do januara 2013. godine, u Jedinici za moždani udar Odeljenja urgentne neurologije Klinike za neurologiju. Rezultati: Vreme praćenja bolesnika od indeksnog AIMU je bilo do sedam godina, uz napomenu da je polovina bolesnika ispitivana minimum tri godine od primene trombolitičke terapije. Nakon perioda praćenja, nije bilo razlike u preživljavanju između dve grupe ispitanika: 56 (21,6%) bolesnika u grupi tromboliziranih je preminulo, naspram 62 (23,9%) u grupi netromboliziranih (Log Rank 0,240, p=0,624). Trombolitička terapija nije imala bitan efekat na preživljavanje bolesnika uprkos povećanom riziku od simptomatske intracerebralne hemoragije. Približno je svaki peti bolesnik preminuo u obe analizirane grupe tokom vremena praćenja. Godine starosti, težina neurološkog deficita, pojava sICH, ranog neurološkog pogoršanja, prethodna upotreba antiagregacione terapije, nepoznat uzrok AIMU i pojava medicinskih komplikacija tokom hospitalizacije su bili prediktori ranog letaliteta (u prvih 30 dana od nastanka AIMU). Godine starosti iznad 70 godina, težak neurološki deficit (NIHSS skor 15 i iznad), dijabetes melitus, atrijalna fibrilacija, medicinske komplikacije tokom hospitalizacije su bili prediktori dugoročnog mortaliteta. Odličan funkionalni oporavak tri meseca nakon AIMU bio povezan sa smanjenim rizikom od umiranja tokom perioda praćenja. Ključni rezultat ovog istraživanja je da se povoljan efekat trombolitičke terapije na funkcionalni oporavak održavao i nakon medijane vremena praćenja od tri godine od inicijalnog AIMU. Tako je odličan funkcionalni oporavak nakon perioda praćenja imalo oko 55% bolesnika u grupi tromboliziranih, naspram 43% u grupi netromboliziranih bolesnika (HR 1,64; 95% CI 1,16-2,32)...Background and Purpose: It remains unclear whether intravenous thrombolytic treatment with recombinant tissue plasminogen activator has an impact on the survival and maintenance of a favorable effect on functional recovery over a longer follow-up period. The aim of this study was to assess whether thrombolytic treatment has a favorable effect on functional recovery and survival more than one year after the stroke. Methods: This matched cohort study included 259 patients with acute IS treated with thrombolytic treatment plus standard care and 259 patients treated with standard care alone in the Stroke Unit in period from February 2006 to January 2013. Results: After the median follow-up period of 3 years (range 1 to 7 years), survival did not differ significantly between groups: 56 (21.6%) patients in thrombolyzed group versus 62 (23.94%) patients in non- thrombolyzed group died (Log Rank 0.240, p=0.624). In multivariate Cox proportional-hazards regression model older age, stroke severity, prior use of antiplatelet, occurrence of symptomatic ICH and medical complications during hospitalization were independent predictors of short term (30 days) mortality after stroke. In multivariate Cox proportional-hazards regression model older age (more than 70 years old), stroke severity (NIHSS≥15), history of diabetes mellitus and atrial fibrillation were independent predictors of long term mortality after stroke, while the excellent functional recovery three months after stroke was associated with a reduced risk of dying during the follow-up period. After follow- up period, 55% patients in IVT treated group versus 43% patients in control group had an excellent outcome- modified Rankin score 0-1 (HR 1.64, 95% CI 1.16-2.32). In multivariate Cox proportional-hazards regression model IVT treatment and decrease in NIHSS score in the first 24 h after treatment (8 point decrement or NIHSS 0) were positive predictors of an excellent stroke outcome . Adding the excellent three-month recovery in the multivariate model, this variable becomes the only strong predictor of outcome, HR 11.27; 95% CI 6.45-19.63; p<0.001. Medication persistence was higher among IVT- treated patients compared to non- IVT- treated patients. After adjustment for possible variables IVT was independent predictor of returning to full time job..