Pandemic-related delays in thrombolysis worsens outcomes

Patients who have had to delay their intravenous thrombolysis (IVT) procedures due to the COVID-19 pandemic suffer from worse short-term clinical outcomes such as higher rates of mortality and hospice care, reports a study presented at the Annual Meeting of the American Academy of Neurology (AAN 2022). These patients are also less likely to be discharged to their homes or to rehabilitation facilities.

Drawing from nine comprehensive stroke centres across the US, researchers conducted a nested observational cohort study including 676 adult ischaemic stroke patients (median age 70 years, 46.3 percent women) who received IVT. Clinical characteristics and outcomes were compared between patients who were admitted before the pandemic (1 January 2019 to 19 February 2020) and those who were hospitalized during the early phase of the pandemic (1 March 2020 to 31 July 2020).

At baseline, participants had a median National Institutes of Health Stroke Scale score of 8 (interquartile range, 4–16). During the early COVID-19 phase, IVT treatment was delayed by a median of 46 minutes, significantly longer than the 38-minute delay during the reference time period (p=0.01). [Koneru S, et al, AAN 2022]

Crude logistic regression analysis revealed that such delays were associated with in-hospital death or discharge to hospice care (odds ratio [OR] per additional hour of delay, 1.08, 95 percent confidence interval [CI], 1.01–1.17; p=0.03).

Of note, multivariable adjustment even strengthened this effect, increasing such likelihood by 15 percent for every additional hour IVT was delayed (adjusted OR, 1.15, 95 percent CI, 1.07–1.24; p<0.001).

Similarly, each hour delay in IVT led to a 7-percent drop in the odds of being discharged to their homes or to a rehabilitation facility (adjusted OR, 0.93, 95 percent CI, 0.89–0.97; p<0.001).

“The COVID-19 pandemic has had a deleterious impact on healthcare systems across the world,” the researchers said. “Delays in presentation and management of emergent medical conditions like myocardial infarction and stroke have been reported, with a recent multicentre cohort study demonstrating that the COVID-19 pandemic has led to delays in IVT administration.”

The current study adds to a growing body of research that pandemic-related fears and movement restrictions force delays in treatment for various diseases, leading to deleterious outcomes.

Earlier this year, a single-centre study in the Philippines found that cancer patients commonly cite logistical hindrances as the number one reason for their treatment delays, which is in turn associated with a significantly elevated risk of disease progression. [Cancer Rep 2022;5:e1426]

In fact, even as early as 2020, experts were already pointing out how the pandemic was causing delays in care-seeking for cardiovascular diseases. A nationwide study in Turkey, for instance, reported significant delays in acute myocardial infarction treatment. Furthermore, though percutaneous coronary interventions were given in a timely fashion, such delays could still contribute to excess rates of major adverse cardiovascular events. [Anatol J Cardiol 2020;24:334-342]