Original Article
Feasibility and Safety of Intravenous Thrombolysis in Multiethnic Asian Stroke Patients in Singapore

https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.07.015Get rights and content

Treatment rates with intravenously administered tissue plasminogen activator (IV-tPA) in acute ischemic stroke (IS) remain low in Asian populations. Various logistic obstacles and higher anticipated bleeding risk in Asians are major concerns. We report on the feasibility and safety of IV-tPA therapy at our tertiary care center. Consecutive acute IS patients eligible for thrombolysis were treated with low-dose (maximum 50 mg) IV-tPA between January 2000 and September 2006 and with standard-dose (maximum 90 mg) IV-tPA between October 2006 and May 2008. The efficacy of IV-tPA was assessed by the modified Rankin Scale (mRS) score at 3 months and by absolute changes in the National Institute of Health Stroke Scale (NIHSS) score at hospital discharge and 3 months. The safety of IV-tPA was assessed by the rate of symptomatic intracranial hemorrhage (SICH). A total of 130 patients were included (mean age, 60 ± 13years; 60% males; median NIHSS score, 14). A total of 48 patients received low-dose IV-tPA, and 82 patients received standard-dose IV-tPA. The median onset to treatment time was 160 minutes. Some 59% of the patients achieved functional independence (mRS score 0-1) at 3 months with standard-dose tPA, compared with 35% in the low-dose group (P = .011). SICH occurred more frequently with the low dose (14.5%) than with the standard dose (1.2%; P = .004). In a multivariate logistic regression model, lower admission NIHSS score (odds ratio [OR] = 0.78 per 1-point increase; 95% confidence interval [CI] = 0.70-0.88), lower pretreatment blood glucose level (OR = 0.76 per 1 mmol/L increase; 95% CI = 0.60-0.95), shorter time from symptom onset to IV-tPA bolus (OR = 0.97 per 1-minute increase; 95% CI = 0.94-1.0), and standard-dose IV-tPA (OR = 12.49; 95% CI = 2.9-53.89) were associated with a higher likelihood for functional independence at 3 months. Our data indicate that standard-dose IV-tPA (0.9 mg/kg) was feasible and safe for treating acute IS in our multiethnic Asian population in Singapore.

Section snippets

Subjects and Methods

In our hospital, patients with acute IS were first attended by the emergency room physicians and nursing staff. If the patient was a potential candidate for thrombolysis, our comprehensive acute stroke team consisting of the stroke neurologist and radiologist, as well as the laboratory staff, was activated for a fast-track evaluation. By the time that the noncontrast computed tomography (CT) scan of the brain was completed, routine laboratory tests (ie, complete blood count, prothrombin time,

Results

Our stroke unit managed a total of 4774 patients with acute IS between January 2000 and June 2008. The rate of thrombolysis during the study period is shown in Figure 1. A total of 130 patients (2.7%) received IV-tPA. Table 1 gives demographic characteristics, vascular risk factors, stroke subtype, and baseline clinical parameters are given in Table 1. Our study sample had a mean age of 60 years, and 60% were men. The ethnic distribution was fairly representative of that in the general

Discussion

Our findings show that thrombolytic therapy with IV-tPA is feasible as well as safe for the treatment of acute IS in our multiethnic Asian patients in Singapore. Studies of IV-tPA therapy in Asian patients are scarce and include smaller numbers of subjects of single ethnic origins.5, 6, 7, 16 To the best of our knowledge, this is the first report on IV-tPA treatment in a cohort of acute IS patients of diverse Asian ethnicity.

Our experience illustrates the “learning curve” in the development of

Acknowledgments

We thank all of the nurses, paramedical staff, emergency physicians, neurologists in our department, as well as the residents involved in the management of acute stroke patients. Our thrombolysis program would not have been possible without their dedication and valuable contributions.

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