Khawja A Siddiqui

Baseline Predictors of Poor Outcome in Patients Too Good to Treat With Intravenous Thrombolysis

Background and Purpose— Several studies have reported poor outcomes in patients too good to treat with intravenous thrombolysis because of mild or rapidly improving symptoms. We sought to determine baseline clinical and imaging predictors of poor outcome in these patients. Methods— Among 3950 consecutive stroke admissions (2009–2015) in our local Get With the Guidelines–Stroke database, 632 patients presented ⩽4.5 hours and did not receive tissue-type plasminogen activator, with 380 of 632 (60.1%) being too good to treat. Univariate and multivariable analyses explored the clinical and imaging features associated with poor outcome (defined as not being discharged to home) in these 380 cases. Results— Among these 380 cases, only 68% were discharged home; the other 25% to inpatient rehabilitation, 4% to a skilled nursing facility, and 3% expired or were discharged to hospice. Patients with poor outcome were older, were more often Hispanic, had more vascular risk factors, and had higher median National Institutes of Health Stroke Scale. Imaging characteristics associated with poor outcomes included large or multifocal infarction and poor collaterals. In multivariable analysis, only age, initial National Institutes of Health Stroke Scale, and infarct location were independently associated with poor outcome. Conclusions— Approximately one third of patients deemed too good for intravenous tissue-type plasminogen activator are unable to be discharged directly to home. Given the current safety profile of intravenous tissue-type plasminogen activator, our results suggest that the concept of being too good to treat should be re-examined with an emphasis on the features associated with poor outcome identified in our study. If replicated, these findings could be incorporated into tissue-type plasminogen activator decision-making algorithms.

Relationship Between Language Preference and Intravenous Thrombolysis Among Acute Ischemic Stroke Patients

Background Approximately 20% of the US population primarily speaks a language other than English at home. Yet the effect of language preference on treatment of acute ischemic stroke (AIS) patients remains unknown. We aimed to evaluate the influence of language preference on AIS patients’ receipt of intravenous (IV) thrombolysis. Methods and Results We analyzed data from 3894 AIS patients who participated in the American Heart Association “Get With The Guidelines®—Stroke” program at our hospital from January 1, 2003 to April 30, 2014. Information included patients’ language in which they preferred to receive medical care. We used descriptive statistics and stepwise logistic regression models to examine associations between patients’ language preference and receipt of IV thrombolysis, adjusting for relevant covariates. A total of 306/3295 (9.3%) AIS patients preferred to speak a non‐English language and represented 25 different languages. Multivariable analyses adjusting for other socioeconomic factors showed that non‐English‐preferring patients were more likely than English‐preferring patients to receive IV thrombolysis (OR=1.64; CI=1.09‐2.48; P=0.02). However, in models that also included age, sex, and initial NIH Stroke Scale, patients’ language preference was no longer significant (OR 1.38; CI=0.88‐2.15; P=0.16), but NIH Stroke Scale was strongly associated with receiving IV thrombolysis (OR=1.15 per point; CI=1.13‐1.16; P<0.0001). Conclusions Contrary to our hypothesis, non‐English‐preferring was not associated with lower rates of IV thrombolysis among AIS patients once initial stroke severity was accounted for.

Prestroke selective serotonin reuptake inhibitor use and functional outcomes after ischaemic stroke

Background Selective serotonin reuptake inhibitors (SSRIs) have been implicated in contributing to recovery after acute ischaemic stroke. In particular, poststroke initiation of an SSRI has been demonstrated to improve motor recovery. The role of prestroke SSRI use on functional outcomes and stroke recovery is less clear. We aimed to examine the effect of prestroke SSRI use on metrics of hospitalisation and functional recovery. Methods We included 4968 consecutive patients from January 2006 to June 2015 in our local Get With The Guidelines-Stroke registry in whom a preadmission drug list could be extracted from an administrative research data registry. Univariate and multivariate analyses were performed to identify predictors of functional outcomes. Results On univariate analysis, among 4698 ischaemic strokes (740 SSRI users and 3948 non-users), SSRI use before acute ischaemic stroke did not impact the National Institutes of Health Stroke Scale (NIHSS) admission score, length of stay or rate of symptomatic haemorrhage. Patients using SSRIs prior to their stroke were more likely to present with weakness (57% vs 47.3%; P<0.001) and have hospitalisations complicated by pneumonia (7.6% vs 5.7%; P<0.001). Moreover, prestroke SSRI use was associated with a negative impact on ambulatory status at discharge and discharge to home. On multivariate regression analysis, SSRI use was associated with lower likelihood of discharge to home (adjusted OR 0.79, 95% CI 0.62 to 0.997, P<0.05). Conclusions SSRI use preceding an acute ischaemic stroke is associated with lower rates of discharge to home despite no significant increase in length of stay or NIHSS score.

Professional Medical Interpreters Influence the Quality of Acute Ischemic Stroke Care for Patients Who Speak Languages Other than English

Background The inability to communicate effectively in a common language can jeopardize clinicians’ efforts to provide quality patient care. Professional medical interpreters (PMIs) can help provide linguistically appropriate health care, in particular for the >25 million Americans who identify speaking English less than very well. We aimed to evaluate the relationship between use of PMIs and quality of acute ischemic stroke care received by patients who preferred to have their medical care in languages other than English. Methods and Results We analyzed data from 259 non–English‐preferring acute ischemic stroke patients who participated in the American Heart Association Get With The Guidelines–Stroke program at our hospital from January 1, 2003, to April 30, 2014. We used descriptive statistics and logistic regression models to examine associations between involvement of PMIs and patients’ receipt of defect‐free stroke care. A total of 147 of 259 (57%) non–English‐preferring patients received PMI services during their hospital stays. Multivariable analyses adjusting for other socioeconomic factors showed that acute ischemic stroke patients who did not receive PMIs had lower odds of receiving defect‐free stroke care (odds ratio: 0.52; P=0.04). Conclusions Our findings suggest that PMIs may influence the quality of acute ischemic stroke care.