title: Patient refusal of thrombolytic therapy for suspected acute ischemic stroke.
abstract: OBJECTIVE
  To determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA.
  
  
  METHODS
  Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0-1), good (mRS: 0-2), and poor (mRS: 3-6).
  
  
  RESULTS
  Over 7·5 years, 30 (4·2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0·63, 95% CI 0·50-0·79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1·02, 95% CI 1·01-1·03), lower NIHSS (OR 1·11, 95% CI 1·03-1·18), a higher proportion of stroke mimics (OR 17·61, 95% CI 6·20-50·02) and shorter hospital stay (OR 1·32, 95% CI 1·09-1·61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1·37, 95% CI 1·06-1·78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1·61, 95% CI 0·69-3·73).
  
  
  CONCLUSIONS
  The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out of six refusal patients (16·6%) had a stroke mimic.
authors.affiliation: Department of Neurology, University of Texas Medical School, Houston, TX, USA.
authors.forename: F S
authors.initials: FS
authors.lastname: Vahidy
authors.affiliation: Division of Epidemiology, Human Genetics and Environmental Sciences (EHGES), School of Public Health, The University of Texas Health Science Center, Houston, TX, USA.|Biostatistics/Epidemiology/Research Design (BERD) Core, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center, Houston, TX, USA.
authors.forename: M H
authors.initials: MH
authors.lastname: Rahbar
authors.affiliation: Department of Neurology, University of Texas Medical School, Houston, TX, USA.
authors.forename: A P
authors.initials: AP
authors.lastname: Lal
authors.affiliation: Department of Neurology, University of Texas Medical School, Houston, TX, USA.
authors.forename: J C
authors.initials: JC
authors.lastname: Grotta
authors.affiliation: Department of Neurology, University of Texas Medical School, Houston, TX, USA.
authors.forename: S I
authors.initials: SI
authors.lastname: Savitz
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000188:drug therapy* / Q000453:epidemiology / Q000523:psychology; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011336:Probability; D012042:Registries; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012737:Sex Factors; D020521:Stroke / Q000188:drug therapy* / Q000453:epidemiology / Q000523:psychology; D015912:Thrombolytic Therapy / Q000523:psychology; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D016312:Treatment Refusal / Q000523:psychology
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator