TIA和小卒中患者院前延误及院内卒中复发研究
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摘要
背景：
短暂性脑缺血发作(TIA)和小卒中作为非致残性的急性脑血管病,发生后即面临着卒中复发的高风险,及时评估并合理治疗可以有效降低风险。多家指南指出TIA和小卒中在发病后24小时内应得以评估。然而事实上许多患者因院前延误未能及时诊治,同时在TIA和小卒中患者急性期的管理上存在很大差异,一些医疗政策提供紧急住院治疗,而另一些医疗政策仅提供门诊评估。对于中国TIA和小卒中患者急性期如何管理以及院内卒中复发影响因素我们知之甚少。
目的：
本研究旨在评估中国TIA和小卒中患者急性期的管理,进一步明确这些患者院前延误和院内复发的影响因素。
方法：
以前瞻性、多中心的中国国家卒中登记研究(The China National Stroke Registry, CNSR)中TIA和小卒中患者为研究人群,收集同期在132家医院就诊患者的人口学信息、危险因素、入院时临床特点等信息,选择和院前延误及院内卒中复发的相关因素,进行单因素和多因素分析,从而明确TIA和小卒中患者院前延误和院内复发的影响因素。
结果：
有7467例患者连续入组进行院前延误的分析研究,其中TIA患者1204例,小卒中6263例。780例(64.78%)TIA患者和3467例(55.36%)小卒中患者没有及时就诊(院前延误>24小时),对于TIA和小卒中患者及时就诊(院前延误≤24小时)均相关的是应用救护车转运或直接到急诊就诊。老年(65-80岁)、起病时运动系统或感觉系统症状、言语吞咽障碍、房颤、既往TIA史、居住在中、东部的小卒中患者倾向于及时就诊。而女性、有认知障碍和糖尿病的小卒中患者倾向于不及时就诊。发病时运动系统症状的TIA患者易于及时就诊,而头痛头晕起病的患者不易于及时就诊。在24小时内到院的4247例TIA和小卒中患者中,61.05%(2593例)患者应用救护车或直接急诊就诊。关于应用救护车或到急诊就诊的相关因素的多因素分析显示,发病时意识障碍(OR3.129,95%CI2.397-4.084)、言语吞咽障碍(OR1.343,95%CI1.208-1.493)、房颤(OR1.539,95%CI1.180-2.007)和卒中家族史(OR1.290,95%CI1.107-1.504)是应用救护车或到急诊就诊预测因素。而老年患者(65-74岁)和年轻患者相比倾向于不应用救护车或直接急诊就诊(OR0.765,95%CI0.612-0.956),既往TIA史(OR0.757,95%CI0.616to0.929)同样倾向于不应用救护车或直接急诊就诊。进入院内卒中复发研究的患者6467例,在平均住院17.27天内,458例(7.08%)TIA或小卒中患者卒中复发,复发的预测因素有：老年(>70岁)(OR2.163,95%CI1.719to2.720)、发病时运动系统症状(OR2.228,95%CI1.786-2.720)、意识障碍(OR2.863,95%CI2.023-4.052).糖尿病(OR1.361,95%CI1.102-1.681)、冠心病(OR2.812,95%CI3.888-6.865).房颤(OR1.509,95%CI1.258-3.152)、心功能不全(OR1.139,95%CI1.438-6.852)、既往缺血性卒中史(OR1.428,95%CI1.136to1.794)。
结论：
TIA和小卒中发生后近一半患者未能及时就诊,应用救护车及到急诊就诊和及时就诊相关联,关于卒中症状识别的健康教育应积极开展；TIA和小卒中发生后应用救护车及到急诊就诊比率偏低,老年、既往TIA史及不发达地区可能与现况关联；TIA和小卒中院内卒中复发和年龄>70岁,发病时运动系统症状、意识障碍,糖尿病,冠心病,房颤,心功能不全及既往缺血性卒中相关联。
Background:
Transient ischaemic attack (TIA) and minor stroke are nondisabling medical emergencies associated with a high risk of early recurrent stroke. Recent studies have shown that prompt assessment and treatment after TIA and minor stroke can substantially reduce the risk of early recurrent stroke. Guidelines recommend that patients with TIA or minor stroke be worked up and treated expeditiously. Despite these advances in management of both minor stroke and TIA, many patients are slow to seek medical advice after a vascular event. Meanwhile, there is considerable international variation in how patients with suspected TIA or minor stroke are managed in the acute phase, some healthcare systems providing immediate emergency inpatient care and others providing non-emergency outpatient clinic assessment. Little is known about how patients with TIA and minor stroke are managed in China and which factors are associated with in-hospital stroke recurrence.
Objectives: We sought to assess how patients with TIA and minor stroke are managed in China, and to seek factors resulting prehospital delay and in-hospital recurrence.
Methods:
Using data from the CNSR (The China National Stroke Registry), patients with TIA and minor stroke admitted to132urban hospitals across China were identified. Factors associated with the delays in seeking medical attention and in-hospital recurrences in these patients were identified. Univariate and multivariate analyses were performed to seek the correlation with the delays and recurrences.
Results:
Of7467patients entered into the CNSR (1204with TIA,6263with minor stroke),780(64.78%) with TIAs and3467(55.36%) with minor strokes had delayed presentation to study hospitals(>24hours). In both groups, factors associated with seeking medical attention quicker (<24hours) include the use of ambulance services and direct presentation to emergency room(ER). After a minor stroke, there was less prehospital delay (≤24hours) if a patient was older (65-80years), having motor and sensory symptoms, speech impairment, atrial fibrillation, previous TIA, and living in central and eastern China. Patients with minor stroke delayed seeking medical help (>24hours) if they were female, or had cognitive dysfunction or diabetes. Patients with motor symptom and TIAs presented to hospitals quicker (<24hours) while patients with headache or vertigo went to hospitals later (>24hours). Of4247patients who sought medical attention within24hours,61.05%(2593) used ambulances or attended ED after minor stroke or TIA. Multivariate analysis demonstrated that consciousness dysfunction(OR3.129,95%CI2.397to4.084) at symptom onset, speech impairment (OR1.343,95%CI1.208to1.493), atrial fibrillation(OR1.539,95%CI1.180to2.007), and have family history of stroke(OR1.290,95%CI1.107to1.504) were significantly associated with utilizing the ambulances or attending an ED. Older patients(65-74years) less likely to use ambulance or attend ED than younger patients (OR0.765,95%CI0.612to0.956), similarly to those who reported having previously TIA (OR0.757,95%CI0.616to0.929). Included in the study of recurrence were6467patients, in-hospital recurrence occurred in458patients (7.08%).The independent variables associated with recurrence were:older (>70years)(OR2.163,95%CI1.719to2.720), motor symptoms(OR2.228,95%CI1.786to 2.720), consciousness disfunction (OR2.863,95%CI2.023to4.052), diabetes (OR1.361,95%CI1.102to1.681), coronary heart disease(OR2.812,95%CI3.888to6.865), atrial fibrillation(OR1.509,95%CI1.258to3.152),heart failure(OR1.139,95%CI1.438to6.852), previous ischemic stroke (OR1.428,95%CI1.136to1.794).
Conclusions:
Many TIAs and minor strokes in China would not seek medical treatment immediately. Much education needs to be done to teach the public about recognizing warning signs and symptoms of TIA and minor stroke, and utilizing ambulances when TIA or stroke occurs. Utilizing EMS or attending ED is not enough. Being elderly, previous TIA and undeveloped region may contribute to this current status. Predictors for in-hospital recurrence were:older (>70years), motor symptoms, consciousness disfunction, coronary heart disease, atrial fibrillation,heart failure and previous ischemic stroke, necessitating adequate attention.
短暂性脑缺血发作(TIA)和小卒中作为非致残性的急性脑血管病,发生后即面临着卒中复发的高风险,及时评估并合理治疗可以有效降低风险。多家指南指出TIA和小卒中在发病后24小时内应得以评估。然而事实上许多患者因院前延误未能及时诊治,同时在TIA和小卒中患者急性期的管理上存在很大差异,一些医疗政策提供紧急住院治疗,而另一些医疗政策仅提供门诊评估。对于中国TIA和小卒中患者急性期如何管理以及院内卒中复发影响因素我们知之甚少。
目的：
本研究旨在评估中国TIA和小卒中患者急性期的管理,进一步明确这些患者院前延误和院内复发的影响因素。
方法：
以前瞻性、多中心的中国国家卒中登记研究(The China National Stroke Registry, CNSR)中TIA和小卒中患者为研究人群,收集同期在132家医院就诊患者的人口学信息、危险因素、入院时临床特点等信息,选择和院前延误及院内卒中复发的相关因素,进行单因素和多因素分析,从而明确TIA和小卒中患者院前延误和院内复发的影响因素。
结果：
有7467例患者连续入组进行院前延误的分析研究,其中TIA患者1204例,小卒中6263例。780例(64.78%)TIA患者和3467例(55.36%)小卒中患者没有及时就诊(院前延误>24小时),对于TIA和小卒中患者及时就诊(院前延误≤24小时)均相关的是应用救护车转运或直接到急诊就诊。老年(65-80岁)、起病时运动系统或感觉系统症状、言语吞咽障碍、房颤、既往TIA史、居住在中、东部的小卒中患者倾向于及时就诊。而女性、有认知障碍和糖尿病的小卒中患者倾向于不及时就诊。发病时运动系统症状的TIA患者易于及时就诊,而头痛头晕起病的患者不易于及时就诊。在24小时内到院的4247例TIA和小卒中患者中,61.05%(2593例)患者应用救护车或直接急诊就诊。关于应用救护车或到急诊就诊的相关因素的多因素分析显示,发病时意识障碍(OR3.129,95%CI2.397-4.084)、言语吞咽障碍(OR1.343,95%CI1.208-1.493)、房颤(OR1.539,95%CI1.180-2.007)和卒中家族史(OR1.290,95%CI1.107-1.504)是应用救护车或到急诊就诊预测因素。而老年患者(65-74岁)和年轻患者相比倾向于不应用救护车或直接急诊就诊(OR0.765,95%CI0.612-0.956),既往TIA史(OR0.757,95%CI0.616to0.929)同样倾向于不应用救护车或直接急诊就诊。进入院内卒中复发研究的患者6467例,在平均住院17.27天内,458例(7.08%)TIA或小卒中患者卒中复发,复发的预测因素有：老年(>70岁)(OR2.163,95%CI1.719to2.720)、发病时运动系统症状(OR2.228,95%CI1.786-2.720)、意识障碍(OR2.863,95%CI2.023-4.052).糖尿病(OR1.361,95%CI1.102-1.681)、冠心病(OR2.812,95%CI3.888-6.865).房颤(OR1.509,95%CI1.258-3.152)、心功能不全(OR1.139,95%CI1.438-6.852)、既往缺血性卒中史(OR1.428,95%CI1.136to1.794)。
结论：
TIA和小卒中发生后近一半患者未能及时就诊,应用救护车及到急诊就诊和及时就诊相关联,关于卒中症状识别的健康教育应积极开展；TIA和小卒中发生后应用救护车及到急诊就诊比率偏低,老年、既往TIA史及不发达地区可能与现况关联；TIA和小卒中院内卒中复发和年龄>70岁,发病时运动系统症状、意识障碍,糖尿病,冠心病,房颤,心功能不全及既往缺血性卒中相关联。
Background:
Transient ischaemic attack (TIA) and minor stroke are nondisabling medical emergencies associated with a high risk of early recurrent stroke. Recent studies have shown that prompt assessment and treatment after TIA and minor stroke can substantially reduce the risk of early recurrent stroke. Guidelines recommend that patients with TIA or minor stroke be worked up and treated expeditiously. Despite these advances in management of both minor stroke and TIA, many patients are slow to seek medical advice after a vascular event. Meanwhile, there is considerable international variation in how patients with suspected TIA or minor stroke are managed in the acute phase, some healthcare systems providing immediate emergency inpatient care and others providing non-emergency outpatient clinic assessment. Little is known about how patients with TIA and minor stroke are managed in China and which factors are associated with in-hospital stroke recurrence.
Objectives: We sought to assess how patients with TIA and minor stroke are managed in China, and to seek factors resulting prehospital delay and in-hospital recurrence.
Methods:
Using data from the CNSR (The China National Stroke Registry), patients with TIA and minor stroke admitted to132urban hospitals across China were identified. Factors associated with the delays in seeking medical attention and in-hospital recurrences in these patients were identified. Univariate and multivariate analyses were performed to seek the correlation with the delays and recurrences.
Results:
Of7467patients entered into the CNSR (1204with TIA,6263with minor stroke),780(64.78%) with TIAs and3467(55.36%) with minor strokes had delayed presentation to study hospitals(>24hours). In both groups, factors associated with seeking medical attention quicker (<24hours) include the use of ambulance services and direct presentation to emergency room(ER). After a minor stroke, there was less prehospital delay (≤24hours) if a patient was older (65-80years), having motor and sensory symptoms, speech impairment, atrial fibrillation, previous TIA, and living in central and eastern China. Patients with minor stroke delayed seeking medical help (>24hours) if they were female, or had cognitive dysfunction or diabetes. Patients with motor symptom and TIAs presented to hospitals quicker (<24hours) while patients with headache or vertigo went to hospitals later (>24hours). Of4247patients who sought medical attention within24hours,61.05%(2593) used ambulances or attended ED after minor stroke or TIA. Multivariate analysis demonstrated that consciousness dysfunction(OR3.129,95%CI2.397to4.084) at symptom onset, speech impairment (OR1.343,95%CI1.208to1.493), atrial fibrillation(OR1.539,95%CI1.180to2.007), and have family history of stroke(OR1.290,95%CI1.107to1.504) were significantly associated with utilizing the ambulances or attending an ED. Older patients(65-74years) less likely to use ambulance or attend ED than younger patients (OR0.765,95%CI0.612to0.956), similarly to those who reported having previously TIA (OR0.757,95%CI0.616to0.929). Included in the study of recurrence were6467patients, in-hospital recurrence occurred in458patients (7.08%).The independent variables associated with recurrence were:older (>70years)(OR2.163,95%CI1.719to2.720), motor symptoms(OR2.228,95%CI1.786to 2.720), consciousness disfunction (OR2.863,95%CI2.023to4.052), diabetes (OR1.361,95%CI1.102to1.681), coronary heart disease(OR2.812,95%CI3.888to6.865), atrial fibrillation(OR1.509,95%CI1.258to3.152),heart failure(OR1.139,95%CI1.438to6.852), previous ischemic stroke (OR1.428,95%CI1.136to1.794).
Conclusions:
Many TIAs and minor strokes in China would not seek medical treatment immediately. Much education needs to be done to teach the public about recognizing warning signs and symptoms of TIA and minor stroke, and utilizing ambulances when TIA or stroke occurs. Utilizing EMS or attending ED is not enough. Being elderly, previous TIA and undeveloped region may contribute to this current status. Predictors for in-hospital recurrence were:older (>70years), motor symptoms, consciousness disfunction, coronary heart disease, atrial fibrillation,heart failure and previous ischemic stroke, necessitating adequate attention.
引文
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