title: Clinical outcomes among stroke patients receiving tissue plasminogen activator therapy beyond the 3-hour time window.
abstract: BACKGROUND
  Tissue plasminogen activator therapy (t-PA) is associated with improved neurologic outcomes and reduced disability from ischemic stroke. The current guidelines stipulate that patients receive t-PA within 3 hours of symptom onset. However, actual practice patterns vary, and little is known about patient outcomes when t-PA is received outside of the recommended time window.
  
  
  METHODS
  We examined mean length of hospital stay, t-PA-related complications, and in-hospital death by time of t-PA administration in North Carolina Stroke Care Collaborative (NCSCC) patients. The NCSCC includes 53 hospitals that enroll patients presenting with stroke-like symptoms. Of 40,907 patients enrolled between January 2005 and February 2010, 1070 (2.6%) received t-PA. Of these, 88.2% received t-PA within 3 hours of symptom onset ("early") and 30.3% received t-PA between 3 and 6 hours after symptom onset ("late").
  
  
  RESULTS
  Unadjusted mean length of stay (days) was longer among early patients (5.0 days; 95% confidence interval [CI], 4.7-5.3) than late patients (3.6 days; 95% CI, 3.1-4.2). t-PA-related complications were similar among early (7.0%; 55/781) and late patients (6.7%; 7/102; P = .89). The proportion of in-hospital deaths was similar among late (10.5%) and early patients (12.0%). We used multivariable logistic regression to estimate odds ratios (ORs) and 95% CIs for the associations between late t-PA status and patient outcomes.
  
  
  CONCLUSIONS
  In models controlling for age, race, sex, arrival mode, and ambulatory status on admission, late t-PA was not associated with increased odds of complications or in-hospital deaths (OR, 0.89; 95% CI, 0.49-1.62). The risks and benefits of expansion of the t-PA time window in stroke patients merit further investigation.
authors.affiliation: Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill 27514-3526, USA. ecobrien@unc.edu
authors.forename: Emily C
authors.initials: EC
authors.lastname: O'Brien
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Rose
authors.forename: Mehul D
authors.initials: MD
authors.lastname: Patel
authors.forename: Carol V
authors.initials: CV
authors.lastname: Murphy
authors.forename: Wayne D
authors.initials: WD
authors.lastname: Rosamond
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D004334:Drug Administration Schedule; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006297:Health Services Accessibility; D006470:Hemorrhage / Q000139:chemically induced; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D009657:North Carolina; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy* / Q000401:mortality; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D013997:Time Factors; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator