切换至 "中华医学电子期刊资源库"

中华脑血管病杂志(电子版) ›› 2021, Vol. 15 ›› Issue (02) : 95 -103. doi: 10.11817/j.issn.1673-9248.2021.02.006

所属专题: 文献

论著

基层医院急性缺血性脑卒中静脉溶栓预后及院内延迟的影响因素分析
郑静维1, 陈英2, 赵性泉3,(), 彭斌4   
  1. 1. 100070 首都医科大学附属北京天坛医院神经内科1;100062 北京市普仁医院老年科2
    2. 100070 首都医科大学附属北京天坛医院神经内科1;100049 北京市石景山医院神经内科3
    3. 100070 首都医科大学附属北京天坛医院神经内科1;100730 北京,中国医学科学院脑血管病人工智能研究创新单元(2019RU018)4
    4. 100730 北京协和医院神经内科
  • 收稿日期:2021-03-08 出版日期:2021-04-01
  • 通信作者: 赵性泉
  • 基金资助:
    中国医学科学院医学与健康科技创新工程项目(2019-I2M-5-029); 北京市科委医药协同科技创新研究专项(Z201100005620010)

Factors associated with prognosis and in-hospital delay of intravenous thrombolysis for patients with acute ischemic stroke in primary hospitals

Jingwei Zheng1, Ying Chen2, Xingquan Zhao3,(), Bin Peng4   

  1. 1. Department of Neurology, Beijing Temple of Heaven Hospital Affiliated to Capital Medical University, Beijing 100070, China; Department of Geriatrics, Beijing Puren Hospital, Beijing 100062, China
    2. Department of Neurology, Beijing Temple of Heaven Hospital Affiliated to Capital Medical University, Beijing 100070, China; Department of Geriatrics, Beijing Shijingshan Hospital, Beijing 100049, China
    3. Department of Neurology, Beijing Temple of Heaven Hospital Affiliated to Capital Medical University, Beijing 100070, China; Innovation Unit for Artificial Intelligence Research on Cerebrovascular Disease (2019RU018), Chinese Academy of Medical Sciences, Beijing 100730, China
    4. Department of Neurology, Beijing Union Hospital, Beijing 100730, China
  • Received:2021-03-08 Published:2021-04-01
  • Corresponding author: Xingquan Zhao
引用本文:

郑静维, 陈英, 赵性泉, 彭斌. 基层医院急性缺血性脑卒中静脉溶栓预后及院内延迟的影响因素分析[J/OL]. 中华脑血管病杂志(电子版), 2021, 15(02): 95-103.

Jingwei Zheng, Ying Chen, Xingquan Zhao, Bin Peng. Factors associated with prognosis and in-hospital delay of intravenous thrombolysis for patients with acute ischemic stroke in primary hospitals[J/OL]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2021, 15(02): 95-103.

目的

探讨基层医院急性缺血性脑卒中(AIS)静脉溶栓预后及院内延迟的影响因素。

方法

收集2017年12月至2019年11月在发病4.5 h内于北京市普仁医院和北京市石景山医院接受重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗的AIS患者的临床资料。以90 d随访的改良Rankin量表(mRS)评分为分组标准,分为预后良好组(90 d mRS评分≤2分)和预后不良组(90 d mRS评分>2分),比较各组间的基线临床资料,观察影响溶栓预后的因素。再根据患者到达医院至静脉溶栓时间(DNT),分为院内延迟(DNT>60 min)组和非院内延迟(DNT≤60 min)组,对2组患者进行Logistic回归分析,筛选静脉溶栓院内延迟的影响因素。

结果

共171例患者纳入本研究,其中预后良好组136例(79.53%),预后不良组35例(20.47%),比较其基线临床资料并行多因素Logistic回归分析,结果显示:患者基线NIHSS评分越高,DNT和最后正常至溶栓开始时间(ONT)越长,静脉溶栓的预后越差[OR(95%CI)分别为1.311 (1.147~1.499)、1.035 (1.006~1.064)、1.013 (1.002~1.025)]。再将入组病例按DNT是否>60 min分组,非院内延迟组139例(81.29%),院内延迟组32例(18.71%),多因素Logistic回归分析结果显示:发病至到院时间长、在常规工作时间就诊的患者,发生静脉溶栓院内延迟的风险较低[OR(95%CI)分别为0.986 (0.973~0.999)、0.208 (0.065~0.719)];而基线收缩压水平升高、基线NIHSS评分高和心源性栓塞患者,发生静脉溶栓院内延迟的风险高[OR (95%CI)分别为1.039 (1.012~1.066)、1.263 (1.112~1.434)、2.978 (1.474~6.018)]。

结论

rt-PA静脉溶栓治疗的AIS患者90 d预后不良与基线NIHSS评分高及治疗延迟有关,进一步探讨可能影响基层医院院内延迟的因素,发现发病至到院时间长、在常规工作时间就诊的患者,不易发生院内延迟;而基线收缩压水平升高、基线NIHSS评分高和心源性栓塞患者,容易发生院内延迟。

Objective

To investigate the factors affecting the prognosis and in-hospital delay of intravenous thrombolysis (IVT) for patients with acute ischemic stroke (AIS) in primary hospitals.

Methods

Patients treated with intravenous administration of alteplase in Beijing Puren Hospital and Beijing Shijingshan Hospital from December 2017 to November 2019 were enrolled in this study. According to mRS at 90 d of following-up, the patients were divided into good prognosis group (≤2 points) and poor prognosis group (>2 points). Based on door-to-needle time (DNT), the patients were divided into two groups: in-hospital delayed (DNT>60 min) group and in-hospital non-delayed (DNT≤60 min) group. Logistic regression analysis was performed to analyze the factors affecting in-hospital delay of IVT for AIS.

Results

A total of 171 patients were enrolled. 136 patients (79.53%) were with good prognosis and 35 patients (20.47%) with poor prognosis. Logistic regression analysis revealed that worse prognosis was associated with higher NIHSS score (OR=1.311, 95%CI: 1.147-1.499), longer DNT (OR=1.035, 95%CI: 1.006-1.064) and longer ONT(onset to needle time) (OR=1.013, 95%CI: 1.002-1.025). 139 patients (81.29%) were in the in-hospital non-delayed group, while 32 cases (18.71%) were in the in-hospital delayed group. Logistic regression analysis showed that longer ODT(onset to door time) (OR=0.986, 95%CI: 0.973-0.999) and administration of patients in routine working hours (OR=0.208, 95%CI: 0.065-0.719) were associated with shorter in-hospital delay. The higher systolic pressure (OR=1.039, 95%CI: 1.01-1.066), and the more NIHSS score (OR=1.263, 95%CI: 1.112-1.434) at baseline, the higher risk of in-hospital delay. And cardioembolism (OR=2.978, 95%CI: 1.474-6.018) was also associated with high risk of in-hospital delay.

Conclusion

This study suggested that poor prognosis of patients with AIS after IVT was related to higher NIHSS and longer DNT/ONT. We further explored that DNT, in routine working hours, NIHSS score, systolic pressure at baseline and cardioembolism were the independent factors affecting the in-hospital delay of IVT for AIS.

表1 静脉溶栓预后良好组(90 d mRS评分≤2分)与预后不良组(90 d mRS评分>2分)基线临床资料比较
变量 预后良好组(n=136) 预后不良组(n=35) 统计值 P
年龄(岁,
x¯
±s)
69.18±9.02 71.13±9.45 t=1.190 0.236

<60岁[例(%)]

45(33.09) 9(25.71) χ2=5.170 0.076

60~80岁[例(%)]

68(50.00) 14(40.00)

>80岁[例(%)]

23(16.91) 12(34.29)
男性[例(%)] 94(69.12) 19(54.29) χ2=2.730 0.098
既往病史[例(%)]

高血压

89(65.44) 28(80.00) χ2=2.730 0.098

糖尿病

44(32.35) 6(17.14) χ2=3.110 0.078

血脂异常

32(23.53) 4(11.43) χ2=2.450 0.117

冠心病

38(27.94) 14(40.00) χ2=1.910 0.167

心房颤动

13(9.56) 8(22.86) χ2=4.570 0.033

卒中或TIA

34(25.00) 8(22.86) χ2=0.070 0.792
基线NIHSS评分[分,MQR)] 4.50(2.00,7.75) 4.00(2.00,9.75) Z=3.904 0.045

轻度(≤8)[例(%)]

115(84.56) 26(74.29) χ2=9.110 0.011

中度(9~15)[例(%)]

18(13.24) 4(11.43)

重度(≥16)[例(%)]

3(2.20) 5(14.28)
基线收缩压(mmHg,
x¯
±s)
157.99±18.68 166.82±18.19 t=2.424 0.028
基线舒张压(mmHg,
x¯
±s)
88.41±13.39 90.16±14.32 t=0.658 0.462
基线快速血糖值(mmol/L,
x¯
±s)
6.78±1.55 8.65±1.40 t=6.259 <0.001
TOAST分型[例(%)] χ2=4.300 0.231

大动脉粥样硬化性

104(76.47) 26(74.28)

小动脉闭塞性

13(9.56) 1(2.86)

心源性栓塞

13(9.56) 7(20.00)

其他病因或不明原因

6(4.41) 1(2.86)
DNT(min,
x¯
±s)
50.46±20.44 61.82±18.63 t=3.290 0.002
ONT(min,
x¯
±s)
138.03±47.16 157.38±39.68 t=2.151 0.049

<3 h[例(%)]

132(97.06) 30(85.71) χ2=5.090 0.007

3~4.5 h[例(%)]

4(2.94) 5(14.29)
SICH[例(%)] 2(1.47) 2(5.71) χ2=2.194 0.139
表2 影响溶栓预后的单因素Logistic回归分析
表3 影响溶栓预后的多因素Logistic回归分析
表4 静脉溶栓院内延迟组(>60 min)与非院内延迟组(≤60 min)基线临床资料比较
表5 院内延迟相关因素的单因素分析
表6 影响院内延迟的多因素Logistic回归分析
表7 静脉溶栓相关时间因素分析(min,
xˉ
±s)
表8 院内延迟组与非院内延迟组静脉溶栓预后分析
1
魏衡, 余勇飞, 周瑞, 等. HAT、SEDAN评分及相关脑血管病危险因素预测急性缺血性卒中溶栓后出血性转化临床研究 [J]. 中国现代神经疾病杂志, 2015, 15(2): 126-132.
2
Wang W, Jiang B, Sun H, et a1. Prevalence, incidence, and mortality of stroke in China: results from a nationwide population-based survey of 480 687 adults [J]. Circulation, 2017, 135(8): 759-771.
3
Wang D, Liu J, Liu M, et a1. Patterns of stroke between university hospitals and nonuniversity hospitals in mainland China: prospective multicenter hospital-based registry study [J]. World Neurosurg, 2017, 98: 258-265.
4
中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018 [J]. 中华神经科杂志, 2018, 51(9): 666-682.
5
Jauch EC, Saver JL, Adams HP, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [J]. Stroke, 2013, 44(3): 870-947.
6
Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials [J]. Lancet, 2004, 363(9411): 768-774.
7
Group ISTc, Sandercock P, Wardlaw JM, et al. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6h of acute ischemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial [J]. Lancet, 2012, 379(9834): 2352-2363.
8
中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2014 [J]. 中华神经科杂志, 2015, 48(4): 246-257.
9
Jauss M, Oertel W, Allendoerfer J, et al. Bias in request for medical care and impact on outcome during office and non-office hours in stroke patients [J]. Eur J Neurol, 2009, 16(10): 1165-1167.
10
Hallevi H, Grotta JC. SITS-MOST: old myths laid to rest [J]. Lancet Neurol, 2007, 6(4): 292-293.
11
Muchada M, Rubiera M, Rodriguez-Lunad D, et al. Baseline national institutes of health stroke scale-adjusted time window for intravenous tissue-type plasminogen activator in acute ischemic stroke [J]. Stroke, 2014, 45(4): 1059-1063.
12
Dharmasaroja PA, Muengtaweepongsa S, Dharmasaroja P. Early outcome after intravenous thrombolysis in patients with acute ischemic stroke [J]. Neurology India, 2011, 59(3): 351-354.
13
Saver JL, Fonarow GC, Smith EE, et al. Time to treatment with intravenous tissue plasminogen activeor and outcome from acute ischemic stroke [J]. JAMA, 2013, 45(5): 2480-2488.
14
Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes [J]. Circulation, 2011, 123(7): 750-758.
15
Xian Y, Smith EE, Zhao X, et al. Strategies used by hospitals to improve speed of tissue-type plasminogen activator treatment in acute ischemic stroke [J]. Stroke, 2014, 45(5): 1387-1395.
16
Gan Y, Wu J, Zhang S, et al. Prevalence and risk factors associated with stroke in middle-aged and older Chinese: a community-based cross-sectional study [J]. Sci Rep, 2017, 7(1): 9501.
17
Bang OY, Saver JL, Alger JR, et al. Determinants of the distribution and severity of hypoperfusion in patients with ischemic stroke [J]. Neurology, 2008, 71(22): 1804-1811.
18
Lima FO, Furie KL, Silva GS, et al. The pattern of leptomeningeal collaterals on CT angiography is a strong predictor of long-term functional outcome in stroke patients with large vessel intracranial occlusion [J]. Stroke, 2010, 41(10): 1316-1322.
19
Ferrari J, Knoflach M, Kiechl S, et al. Stroke thrombolysis: having more time translates into delayed therapy: data from the Austrian Stroke Unit Registry [J]. Stroke, 2010, 41(9): 2001-2004.
20
Ogbu UC, Westert GP, Slobbe LC, et al. A multifaceted look at time of admission and its impact on case-fatality among a cohort of ischaemic stroke patients [J]. J Neurol Neurosurg Psychiatry, 2011, 82(1): 8-13.
21
Bray BD, Cloud GC, James MA, et al. Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care [J]. Lancet, 2016, 388(10040): 170-177.
22
浙江省缺血性脑卒中静脉溶栓的临床行为干预研究协作组, 泮飞虎, 楼敏, 陈智才, 等. 不同工作时间段就诊对缺血性脑卒中患者静脉溶栓预后的影响 [J]. 浙江大学学报(医学版), 2019, 48(3): 267-274.
23
杨涌涛, 金戈, 陈亮, 等. 急性缺血性卒中静脉溶栓后出血转化影响因素的临床研究 [J]. 癫痫与神经电生理学杂志, 2019, 28(4): 213-217, 225.
24
Mazya MV, Lees KR, Collas D, et al. Ⅳ thrombolysis in very severe and severe ischemic stroke: results from the SITS-ISTR registry [J]. Neurology, 2015, 85(24): 2098-2106.
25
Muengtaweepongsa S, Prapa-Anantachai P, Dharmasaroja PA. Not only the sugar, early infarct sign, hyperdense middle cerebral artery, age, neurologic deficit score but also atrial fibrillation is predictive for symptomatic intracranial hemorrhage after intravenous recombinant tissue plasminogen activator [J]. J Neurosci Rural Pract, 2017, 8(1): 49-54.
26
Kimura K, Iguchi Y, Shibazaki K, et al. Ⅳ rt-PA therapy in acute stroke patients with atrial fibrillation [J]. J Neurol Sci, 2009, 276(1-2): 6-8.
27
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke [J]. N Engl J Med, 1995, 333(24): 1581-1587.
28
Lattanzi S, Silvestrini M, Provinciali L. Elevated blood pressure in the acute phase of stroke and the role of Angiotensin receptor blockers [J]. Int J Hypertens, 2013, 2013: 941783.
29
Ahmed N, Wahlgren N, Brainin M, et al. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) [J]. Stroke, 2009, 40(7): 2442-2449.
30
Meretoja A, Weir L, Ugalde M, et al. Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months [J]. Neurology, 2013, 81(12): 1071-1076.
31
金云龙, 王志敏, 王鹏, 等. 多中心基层医院急性缺血性卒中静脉溶栓影响因素分析 [J]. 中国卒中杂志, 2016, 11(5): 386-392.
[1] 张晓宇, 殷雨来, 张银旭. 阿帕替尼联合新辅助化疗对三阴性乳腺癌的疗效及预后分析[J/OL]. 中华乳腺病杂志(电子版), 2024, 18(06): 346-352.
[2] 许杰, 李亚俊, 韩军伟. 两种入路下腹腔镜根治性全胃切除术治疗超重胃癌的效果比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 19-22.
[3] 高杰红, 黎平平, 齐婧, 代引海. ETFA和CD34在乳腺癌中的表达及与临床病理参数和预后的关系研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 64-67.
[4] 李代勤, 刘佩杰. 动态增强磁共振评估中晚期低位直肠癌同步放化疗后疗效及预后的价值[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 100-103.
[5] 梁孟杰, 朱欢欢, 王行舟, 江航, 艾世超, 孙锋, 宋鹏, 王萌, 刘颂, 夏雪峰, 杜峻峰, 傅双, 陆晓峰, 沈晓菲, 管文贤. 联合免疫治疗的胃癌转化治疗患者预后及术后并发症分析[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 619-623.
[6] 公宇, 廖媛, 尚梅. 肝细胞癌TACE术后复发影响因素及预测模型建立[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 818-824.
[7] 陈宗杰, 胡添松. 肝外伤破裂患者治疗后胆漏发生影响因素分析[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 836-840.
[8] 关小玲, 周文营, 陈洪平. PTAAR在乙肝相关慢加急性肝衰竭患者短期预后中的预测价值[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 841-845.
[9] 张润锦, 阳盼, 林燕斯, 刘尊龙, 刘建平, 金小岩. EB病毒相关胆管癌伴多发转移一例及国内文献复习[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 865-869.
[10] 陈晓鹏, 王佳妮, 练庆海, 杨九妹. 肝细胞癌VOPP1表达及其与预后的关系[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 876-882.
[11] 刘郁, 段绍斌, 丁志翔, 史志涛. miR-34a-5p 在结肠癌患者的表达及其与临床特征及预后的相关性研究[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 485-490.
[12] 陈倩倩, 袁晨, 刘基, 尹婷婷. 多层螺旋CT 参数、癌胚抗原、错配修复基因及病理指标对结直肠癌预后的影响[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 507-511.
[13] 曾明芬, 王艳. 急性胰腺炎合并脂肪肝患者CT 与彩色多普勒超声诊断参数与其病情和预后的关联性研究[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 531-535.
[14] 沈炎, 张俊峰, 唐春芳. 预后营养指数结合血清降钙素原、胱抑素C及视黄醇结合蛋白对急性胰腺炎并发急性肾损伤的预测价值[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 536-540.
[15] 王景明, 王磊, 许小多, 邢文强, 张兆岩, 黄伟敏. 腰椎椎旁肌的研究进展[J/OL]. 中华临床医师杂志(电子版), 2024, 18(09): 846-852.
阅读次数
全文


摘要


AI


AI小编
你好!我是《中华医学电子期刊资源库》AI小编,有什么可以帮您的吗?