hidden

Effects of COVID-19 on Acute Ischaemic Stroke care: Comparative insights from Get With The Guidelines-Stroke registry

Much like acute myocardial infarctions, the optimal management of acute ischaemic stroke (AIS) is extremely time-sensitive. The foundation of favorable outcomes of AIS lies in the timely presentation and acute intervention by means of either intravenous thrombolysis and mechanical thrombectomy. Especially earlier on during the COVID-19 pandemic, there was a concern regarding a decline in non-COVID acute medical admissions, as well as hospital-based challenges to appropriate and timely delivery of acute stroke care.

A study led by Dr Pratyaksh Srivastava and colleagues, published in Stroke, uses data from the American Heart Association (AHA)’s Get With The Guidelines Stroke (GWTG-Stroke)® registry, to compare characteristics, treatment patterns, and in-hospital outcomes of 81,084 patients over two time periods: before COVID and after the first reported case of COVID-19 (1). The AHA’s GWTG-Stroke registry is a validated and reliable national registry of adults with stroke in the United States (2,3). This blog provides a brief summary of the key findings of this analysis.

The study cohort and comparisons:

81,084 AIS patients were included over a period extending from 01st November 2019 to 29th June 2020, from among 458 participating hospitals with at least one positive COVID-19 patient. They were divided into two groups, according to the first reported case of COVID-19 in the registry. The pre-COVID group consisting of 39,113 patients (01st November 2019 to 3rd February 2020) and the during COVID group, consisting of 41,971 patients (4th February 2020 to 29th June 2020).

The two groups were compared for characteristics, treatment patterns, and outcomes. These analyses were repeated in sensitivity analyses, comparing a later during COVID-19 time period (1st April 2020 to 29th June 2020) to the same pre-COVID-19 time period. There were no differences in general characteristics among patients of the two time periods. 48.8% of the cohort were women. 61.9% were White. 2.7% of patients in the during COVID-19 group had a diagnosis of COVID-19.

Key findings from the study & implications:

There was a 15.3% average reduction of stroke presentations per week in the during-COVID-time period (3rd February 2020 to 24th May 2020) when compared with similar months in 2019. This is perhaps a reflection of general trends (4,5) in the immediate aftermath of the pandemic, partially reflecting an anticipated lack of capacity in overburdened health systems, the effect of shelters in place and social distancing disorders (5), and patients delaying or avoiding seeking medical care due to concerns of contracting COVID-19(6).

Treatment patterns:

Similar rates of acute interventions for AIS were observed in pre-COVID and during-COVID time periods. There were no differences in rates of intravenous alteplase (11.7% vs. 11.4%, p=0.26) or endovascular therapy (10.2% vs. 10.1%, p=0.90) pre- and during COVID respectively.

Furthermore, there were also no additional delays in administering care. Median door to needle times (46 [32-65] minutes vs 46 [33-64] minutes; p= 0.69) and door to endovascular times (86 [53-129] minutes vs 90 [54-134] minutes; p=0.06) were not different between the pre-COVID and during COVID periods respectively. This is crucial and encouraging data, given the time-sensitive nature of acute stroke care and the delays that were anticipated during the COVID-19 period, from having to don personal protective equipment (PPE).

Also, door to computed tomography (CT) time was slightly shorter during the COVID-19 time period (median 35 [14-100] vs 37 [15-111] mins, p<0.001). A significant uptake of telestroke consult was observed during the COVID-19 period as compared with pre-COVID (6.0% vs 7.1%; p <0.0001).

GWTG-Stroke quality measures: 

Slight decreases were observed in rates of timely IV alteplase administration, prescription of antithrombotics at discharge, dysphagia screen, smoking cessation counseling, stroke education, and rehabilitation consideration in the during-COVID-19 group.  Despite this, these quality measures remained above the 85% target, suggesting the maintenance of quality care during the pandemic.

Outcomes:

Adjusted inpatient mortality of AIS was similar between pre- and during COVID-19 periods (4.8% vs. 5.2%; odd ratio 1.05, 95% CI 0.97-1.13), consistent with prior published studies (5,7). Also, in these adjusted models, no significant differences were observed for other outcomes such as symptomatic intracranial hemorrhage among IV alteplase patients, venous thromboembolism or pulmonary embolism during hospitalization.

In terms of patients’ disposition, there were reduced odds of discharge to skilled nursing facility (OR 0.78, 95% CI 0.74-0.82) and of a hospital stay >4 days during COVID-19 time period (OR 0.84, 95% CI 0.81-0.87), and increased odds of discharge to hospice (1.12, 95% CI 1.03- 1.21), and to home (OR 1.12, 95% CI 1.09-1.16) during COVID-19 period. These possibly reflect a hesitancy towards prolonged hospital stays, competing pressures on beds and skilled facilities, and tendency to triage away from high-risk environments.

Sensitivity analyses:

Apart from a slightly longer, and perhaps clinically insignificant, time from door to endovascular treatment in the later during COVID-19 group, findings remained largely similar in sensitivity analyses comparing those presenting in the later COVID-19 time period to those presenting pre-COVID-19.

Limitations:

Given its retrospective, observational nature, this study is limited in its ability to only evaluate, but not infer causality, with descriptive statistics performed being hypothesis generating. Not all data were complete and the observed decline in AIS patients during the pandemic may be due to lags in data entry. Furthermore, these findings may not be generalizable to hospitals that differ from GWTG-Stroke and international cohorts.

Key take-home message:

Despite an observed 15.3 % average decline in AIS presentations during the pandemic, this analysis from the GWTG-Stroke registry demonstrates preserved AIS care quality in the pre- and during COVID-19 time periods with similar door to needle, and door to endovascular times, similar rates of IV alteplase therapy, endovascular therapy, and adjusted in-hospital mortality.

For more latest science on Stroke and Neurology, be sure to register and attend the International Stroke Conference – happening now!

References

  1. Srivastava PK, Zhang S, Xian Y, et al. Acute Ischemic Stroke in Patients With COVID-19: An Analysis From Get With The Guidelines–Stroke. Stroke. 2021;52:00–00. DOI: 10.1161/STROKEAHA.121.034301
  2. Ormseth CH, Sheth KN, Saver JL, Fonarow GC and Schwamm LH. The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol. 2017;2:94-105
  3. Xian Y, Fonarow GC, Reeves MJ, Webb LE, Blevins J, Demyanenko VS, et al. Data quality in the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke): results from a national data validation audit. Am Heart J. 2012;163:392-8, 398 e1.
  4. Diegoli H, Magalhaes PSC, Martins SCO, Moro CHC, Franca PHC, Safanelli J, Nagel V, Venancio VG, Liberato RB and Longo AL. Decrease in Hospital Admissions for Transient Ischemic Attack, Mild, and Moderate Stroke During the COVID-19 Era. Stroke. 2020;51:2315-2321.
  5. Nguyen-Huynh MN, Tang XN, Vinson DR, Flint AC, Alexander JG, Meighan M, Burnett M,Sidney S and Klingman JG. Acute Stroke Presentation, Care, and Outcomes in Community  Hospitals in Northern California During the COVID-19 Pandemic. Stroke. 2020;51:2918-2924
  6. American College of Emergency Physicians. Public Poll: Emergency Care Concerns Amidst COVID-19 https://wwwemergencyphysiciansorg/article/covid19/public-poll-emergency care-concerns-amidst-covid-19. 2020.
  7. Tejada Meza H, Lambea Gil Á, Sancho Saldaña A, Martínez-Zabaleta M, Garmendia Lopetegui E, López-Cancio Martínez E, et al; NORDICTUS Investigators. Impact of COVID-19 outbreak in reperfusion therapies of acute ischaemic stroke in northwest Spain. Eur J Neurol. 2020;27(12):2491-2498.

 

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

hidden

The Great Terror of Oral Anticoagulant Use: Intracerebral hemorrhage

I am pleased to summarize a recent paper published by Dr. Xian Et.al on the clinical characteristics and outcomes associated with oral anticoagulants (OAC) use among patients hospitalized with intracerebral hemorrhage (ICH)1.

Major question addressed in the paper: 

What is the association between prior oral anticoagulant use (FXa inhibitor, Warfarin or none) and in-hospital outcomes among patients with nontraumatic ICH?

Approach:  

The investigators used the American Heart Association Stroke Association Get with The Guidelines-Stroke (GWTG-Stroke) registry to evaluate patients between October 2013 and May 2018, that had experience non-traumatic ICH with preceding use of FXa inhibitor compared with warfarin or none.  Patients with subarachnoid hemorrhage, subdural hematoma, or taking dabigatran were excluded. Included patients were defined by documentation ICH and use for at least 7 days of OAC, in three different groups: FXa inhibitor (rivaroxaban, apixaban, edoxaban); warfarin, or no use of OAC prior to hospital arrival and ICH.

Main outcomes and measures:

  • Primary outcome: In-hospital mortality
  • Secondary outcome: Composite of in-hospital mortality or discharge to hospice, discharge home, independent ambulation, and modified Rankin Scale (mRS) score at discharge.

Results:

Generals

  • Of 219,701 patients in the study, 104,940 were women (47.8%), 189,069 were not taking any OAC prior to ICH (86%), 9202 were taking FXa Inhibitors (4.2%), and 21,430 (9.8%) were taking warfarin.
  • One third of patients were taking concomitant antiplatelet therapy. This was more prevalent amongst patients taking FXa inhibitor (27%) and warfarin (30.1%) than those without taking OAC (24.8%).
  • NIHSS median score was 9 amongst the three groups. Patients taking warfarin had a higher mean NIHSS (12.5 {SD:11.3}).

Major results

  • FXa inhibitors (aOR: 1.27; p<0.001) and warfarin (aOR: 1.67; p<0.001) were associated with greater odds of in-hospital mortality compared with no OAC.
  • FXa inhibitors (aOR: 1.19; p<0.001) and warfarin (aOR: 1.50; p<0.001) were associated with greater odds of death or discharge to hospice compared with no OAC.
  • Patients with FXa were less likely to die (aOR 0.76; p<0.001) or be discharged to hospice (0.79; p<0.001) compared to those taking Warfarin.
  • Patients taking FXa were more likely to be discharged at home (aOR1.18; p<0.001) and have better mRS scores at discharge (aOR 1.24; p<0.001).
  • No statistical difference was found amongst the three groups regarding rates of discharge home, independent ambulation, or mRS score.
  • The use of single or dual antiplatelet, in patients taking warfarin was associated with higher odds of in-hospital mortality (aOR 2.07; p<0.001), and dead or discharge to hospice (aOR 1.86; p<0.001).

Major study limitations:

  1. The use of OAC use was defined as patients taking them 7 days prior to ICH, however the timing of the last doses of the OAC was not document, and it is possible that some patients might have not taken it or received a lower dose.
  2. Data regarding platelet transfusion was not recorded on the registry, and this might have influenced outcomes.

Key take-home message:

One of the most devastating complications of the use of FXa inhibitors is ICH, and although its prevalence is low (<0.5%), the in-hospital mortality can be as high as 27% as it was found on this study.  Although its high, when compared with prior use of warfarin, taking FXa inhibitors has a lower risk of mortality and dead or discharge to a hospice in the setting of ICH.

Potential future research:

  • Develop prospective studies that compare the available treatments for spontaneous ICH bleeding, four-factor prothrombin complexes concentrate vs. reverse factor Xa inhibitors (Andexanet). An underpowered retrospective study by Ammar et. Al,2 found no difference between these treatments due to the low number of patients analyzed in this study. Due to the burden of this complication we must find the most adequate treatment for non-traumatic ICH in the setting of FXa inhibitor use.

 

References:

  1. Xian Y, Zhang S, Inohara T, et al. Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage. JAMA Network Open. 2021;4(2):e2037438-e2037438.
  2. Ammar AA, Ammar MA, Owusu KA, et al. Andexanet Alfa Versus 4-Factor Prothrombin Complex Concentrate for Reversal of Factor Xa Inhibitors in Intracranial Hemorrhage. Neurocrit Care. 2021.

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”