QJM Advance Access published online on August 11, 2008
QJM, doi:10.1093/qjmed/hcn102
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Thrombolytic therapy for acute stroke in the United Kingdom: experience from the safe implementation of thrombolysis in stroke (SITS) register
From the 1Division of Cardiovascular and Medical Sciences, University of Glasgow 2Institute for Ageing and Health University of Newcastle 3Division of Clinical Neurosciences, University of Glasgow, UK 4Department of Neurology, Karolinska University Hospital, Karolinska Institutet, SE-171 76 Stockholm, Sweden 5The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle 6King's College Schools of Medicine, London 7Department of Clinical Neurosciences, University of Cambridge and 8The Royal Bournemouth & Christchurch Hospitals NHS Trust, Christchurch, UK
Address correspondence to Prof. K.R. Lees, Acute Stroke Unit, Division of Cardiovascular and Medical Sciences, University of Glasgow, G11 6NT, UK. email: m.walters{at}clinmed.gla.ac.uk
Received 20 June 2008 and in revised form 14 July 2008
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Abstract |
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Aim: To describe the United Kingdom (UK) experience with thrombolytic therapy with intravenous alteplase (rt-PA) for stroke, as captured by the Implementation of Thrombolysis in Stroke (SITS) project.
Methods: The multinational Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) was an observational study to assess the safety and efficacy of thrombolytic therapy, when administered within the first 3 h after onset of ischaemic stroke. SITS-MOST was embedded within the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR), an internet-based, international monitoring registry for auditing the safety and efficacy of routine therapeutic use of thrombolysis in acute ischaemic stroke. We performed an analysis of data contributed to SITS-MOST and SITS-ISTR from UK centres.
Results: A total of 614 patients received thrombolysis for stroke between December 2002 and April 2006, 327 were registered to SITS-MOST and 287 to SITS-ISTR. Thirty-one centres treated patients in the UK, of which 23 registered patients in both SITS-MOST and SITS-ISTR and eight solely to SITS-ISTR. The median age from the UK SITS-MOST was identical to the non-UK SITS-MOST register: 68 years (IQR 59–75). The majority (96.1%) of patients from the UK were treated between 8.00 a.m. and 9.00 p.m., and only 18.4% were treated on weekend days, reflecting the difficulties of maintaining provision of a thrombolytic service out of hours. Median onset-to-treatment-time was 155 min (IQR 130–170 min) for the UK, compared to 140 min (IQR 114–165 min) for the non-UK SITS-MOST group (P < 0.001). UK SITS-MOST patients at baseline had more severe stroke in comparison with non-UK patients [median NIHSS 14.5 (IQR 9–19) vs. 12 (IQR 8–17) (P < 0.001)]. Forty-eight percent of UK patients achieved mRS of 0–2 (independence), compared to 55% of the non-UK SITS-MOST register. There was no significant difference in symptomatic intracerebral haemorrhage rate in the UK compared with the non-UK SITS-MOST patients [2.5% (95% CI 1.3–4.8) vs. 1.7% (95% CI 1.4–2.0) P = 0.28]. In the multivariate analysis, there was no statistically significant difference in any outcome between UK and non-UK SITS-MOST patients.
Conclusion: Thrombolytic therapy for stroke has been implemented successfully at a small number of UK stroke centres, with patchy provision throughout the country. The low frequency of treatment outwith office hours suggests deficient infrastructure to support delivery. UK patients tended to be more severely affected at baseline and to be treated later. Outcomes are comparable to those seen at the non-UK SITS centres.