Challenges of Thrombolysis in a Developing Country: Characteristics and Outcomes in Peru

J Stroke Cerebrovasc Dis. 2020 Jul;29(7):104819. doi: 10.1016/j.jstrokecerebrovasdis.2020.104819. Epub 2020 Apr 16.

Abstract

Background: The availability of intravenous tissue plasminogen activator (IV-tPA) remains limited worldwide, especially in low-income countries, where the burden of disability due to ischemic stroke is the highest.

Aims: To evaluate outcomes and safety of IV-tPA at the only Peruvian reference institute for neurologic diseases.

Methods: We conducted a prospective, observational study of stroke patients who received IV-tPA between 2009 and 2016. We assessed characteristics associated with good outcome (modified Rankine scale 0-2) at 3 months using a multivariate regression model; and factors correlated with clinical improvement (delta National Institute of Health Stroke Scale (NIHSS)) using linear regression.

Results: Only 1.98% (39/1,1962) of patients presenting with ischemic stroke received IV-tPA. Nearly half (41%) were younger than 60 years, 56.4 % were men, and most strokes were cardioembolic (46.2%). The majority (64.1%) were treated within 3-4.5 hours. The median NIHSS on admission and discharge was 9 and 4, respectively; 42.1% of patients had an mRS of 0-1 at 3 months. Three patients (7.7%) developed hemorrhagic conversion, and 1 patient died (2.6%). Patients with good outcomes had lower pretreatment systolic blood pressure (138.9 versus 158.1 mm Hg, P < .007), fewer complications during hospitalization (5 versus 9 events, P < .001), shorter hospital stay (14 versus 21 days, P < .03) and, paradoxically, longer last known well -to-door times (148.3 versus 105 minutes, P < .0022). Clinical improvement was associated with shorter door-to-tPA times and obesity.

Conclusions: Our findings indicate that IV-tPA has similar safety and outcomes compared to developed countries. All internal metrics (door-to-tPA, door-to-CT, and CT-to-tPA time) improved over time, highlighting areas for future implementation science studies to further expedite the administration of IV-tPA.

Keywords: Peru; Thrombolysis; acute ischemic stroke; acute stroke treatment; global health; latin America; tPA.

Publication types

  • Observational Study

MeSH terms

  • Administration, Intravenous
  • Adult
  • Aged
  • Aged, 80 and over
  • Developing Countries*
  • Disability Evaluation
  • Feasibility Studies
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Fibrinolytic Agents / adverse effects
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Peru
  • Prospective Studies
  • Quality Indicators, Health Care
  • Recovery of Function
  • Stroke / diagnosis
  • Stroke / drug therapy*
  • Stroke / physiopathology
  • Thrombolytic Therapy* / adverse effects
  • Time Factors
  • Time-to-Treatment
  • Tissue Plasminogen Activator / administration & dosage*
  • Tissue Plasminogen Activator / adverse effects
  • Treatment Outcome

Substances

  • Fibrinolytic Agents
  • Tissue Plasminogen Activator