中国七城市卒中患者急诊溶栓情况分析

目的 超早期重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator，rt-PA）溶栓治疗是缺血性卒中有效的治疗方法，但目前缺血性卒中救治过程中存在溶栓率偏低的问题，本调查的目的在于了解实际溶栓状况及未溶栓原因。方法 本调查在中国的7个城市31家中心展开前瞻性调查，调查采用标准的登记数据，内容包括患者的一般人口学信息、院前卒中急救信息、院前院内关键延误时间、溶栓信息等。结果 在研究期间，共有1091例患者确诊符合入选标准，其中754例（69.6%）急性缺血性卒中患者中共有20例（2.7%）患者溶栓，其中静脉rt-PA15例、动脉rt-PA2例、静脉尿激酶（Urokinase，UK）3例。在静脉rt-PA中，93.3%（14/15）存在方案违背。大部分病例（17/20）在2 h内就到达了医院，院前延迟平均中位时间为1.17 h。急诊接诊到获得检查（CT或磁共振）平均中位时间为0.67 h。未进行溶栓的主要原因除年龄（>80岁或<18岁）（28.9%）、卒中症状太轻（24.0%）、病情迅速恢复（16.5%）、CT影像已有病灶（15.7%）、时间>3 h（15.7%）、卒中症状太重（7.4%）等因素外，患者/家属主观拒绝仍占了18.2%。结论 急性缺血性卒中溶栓比例偏低，溶栓药物使用不规范且存在方案违背，存在院前延迟问题，亟待整合院前急救中心与医院间医疗资源，规范院前转运途径，缩短延误时间，提高溶栓率。

Thrombolysis in the Emergency Department in China: Results from an Emergency Department Registry in 7 Urban Hospitals

Objective Intravenous recombinant tissue plasminogen activator（rt-PA） is the drug of choice for the treatment of acute ischemic stroke within 3 hours of onset, which has been approved for use in China but it is infrequently used. We sought to assess thrombolysis status in Chinese urban hospitals and try to find the reasons of untreatment with rt-PA in the potential eligible patients. Methods Data from Cerebrovascular events Acute care Register Database Study（CARDs） in emergency department（ED）, which was consecutively enrolled patients presented ED in 31 centers in 7 cities of China. The registry includes data on stroke patient characteristics, pre-hospital emergency care, onset to treatment time intervals, stroke evaluation and therapy, and characteristics of patients receiving thrombolysis with rt-PA or urokinase（UK）. Results A total of 1091 patients with diagnosis of stroke or Transient Ischemic Attack（TIA） were included. Of these, only 20（2.7%） of 754（69.6%） ischemic stroke patients received thrombolytic therapy （intravenous rt-PA, n=15; intra-arterial rt-PA, n=2, and intravenous UK, n=3）. Protocol violations occurred in 93.3%（14/15） of patients who received Intravenous rt-PA. Most of patients （17/20） arrived within 2 hours of symptoms onset, the onset-to-door median time was 1.17 hour, and the door-to-imaging （CT or MRI） median time was 0.67 hour. Reasons for not administering thrombolytric therapy were age more than 80 or less than 18（28.9%）, patients too mild （24.0%）, rapidly improving （16.5%）, CT showing lesions（15.7%）, time window when stroke team assessment beyond 3h（15.7%）, too severe deficit（7.4%）, out of expected, no consent accounted for 18.2%. Conclusion Intravenous rt-PA was underutilized and nonstandard in this ED registry in China, and both the onset-to-door time and the imaging-to-needle time were too long. Further studies are needed to elucidate specific barriers to rt-PA use and to develop targeted quality improvement strategies.