Original Research

Outcomes of Treatment with Recombinant Tissue Plasminogen Activator in Patients Age 80 Years and Older Presenting with Acute Ischemic Stroke

Journal of Clinical Outcomes Management. 2015 February;22(2)

Author(s):

References

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From Summa Health System, Akron, OH.

Abstract

Background: Ischemic stroke is a major cause of morbidity and mortality for patients ≥ 80 years old. The use of intravenous recombinant tissue plasminogen activator (tPA) in patients ≥ 80 years for treatment of ischemic stroke remains controversial.
Objective: To examine outcomes in patients ≥ 80 years old who received tPA in our institution.
Methods: This was a retrospective cohort study at a community-based certified acute stroke center. Individuals age ≥ 80 years evaluated emergently for acute neurologic changes consistent with ischemic stroke were included ( n = 184). The comparison groups within this sample were patients who received tPA versus with those who did not because they came to the ED outside of the treatment window. Outcome measures included length of stay, symptomatic intracerebral hemorrhage (ICH), discharge disposition, and in-hospital death
Results: 38 patients (20.7%) received tPA. 50 patients (27.2%) presented outside of treatment windows and were included in comparative analysis. There was no difference between groups in age ( P = 0.26) or initial National Institute of Health Stroke Scale ( P = 0.598). One patient (2.6%) who received tPA developed symptomatic ICH. Those receiving tPA were more likely to be discharged to acute rehabilitation hospitals ( P = 0.012) and less likely to experience in hospital death ( P = 0.048).
Conclusion: At this institution, the use of tPA in patients ≥ 80 years old is not associated with increased mortality or risk of symptomatic ICH. Those who received tPA were more likely to be discharged to acute rehabilitation hospitals, suggesting greater potential for functional recovery.

Acute ischemic stroke is a major cause of morbidity and mortality in patients 80 years or older. Though less than 5% of the United States population is over the age of 80 [1], studies have shown that up to one-third of patients presenting with ischemic stroke are ≥ 80 years old [2] and among first-time strokes, a third occur in those ≥ 80 [3]. Older adults present with worse symptoms associated with ischemic stroke as measured by the National Institutes of Health Stroke Scale (NIHSS) compared with younger (< 80 years) counterparts [4]. Older patients are more likely to be discharged to a location other than home [5]. Older age is associated with higher hospital, 30-day, and 1-year mortality [3,5,6]. Patients ≥ 80 are significantly more likely to die in the hospital compared to younger patients, 11.7% to 23.6% vs 5.1%, respectively [3,7].

The Food and Drug Administration (FDA) approved the use of intravenous recombinant tissue plasminogen activator (tPA) in 1996 for the treatment of ischemic stroke [8]. Studies evaluating the safety and efficacy of tPA in ischemic stroke excluded or underrepresented patients ≥ 80 [8,9]. The use of tPA in those ≥ 80 has not been shown consistently to improve outcomes [6,10,11]. Post-hoc analysis of the National Institute of Neurologic Disorders and Stroke (NINDS) study did not show worse outcomes or harms to older adults treated with tPA [12]. Likewise, data from the International Stroke Treatment (IST-3) collaborative group show that treatment with tPA up to 6 hours from the onset of symptoms improves outcomes in the elderly [13]. Use of tPA in the oldest adults remains controversial due to perceived higher risk of symptomatic intracerebral hemorrhage (ICH). Published data suggest overall ICH risk of 4.3% to 6.4% across all age-groups [9,14,15].Studies have failed to demonstrate an increased risk in the oldest adults [4,10,16,17], though they may have higher mortality rates associated with ICH [15]. Despite this, trends suggest increasing use of tPA in those ≥ 80 over the past decade [2]. Along with primary data from NINDS [12] and IST-3 [13], a meta-analysis conducted in 2014 suggests that regardless of age, patients have improved outcomes with tPA [18].With the increasing age of the population, effective treatment of strokes in patients ≥ 80 will continue to be an important clinical and research endeavor.