In Stroke, Prolonged Prehospital Intervals More Likely in Black Patients

Black patients with acute stroke are more likely to experience a prolonged onset to arrival (OTA) interval and significantly decreased odds of emergency medical services (EMS) prenotification, investigators reported in Circulation.

The retrospective, observational study analyzed data from the American Heart Association (AHA) Get With the Guidelines (GWTG)-Stroke registry from July 2015 to December 2019.

Participants were aged 18 years and older with a diagnosis of ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage and presented to the emergency department (ED) within 24 hours of symptom onset.

The 3 primary outcomes were EMS transport to the ED (vs private transport), EMS prehospital notification when transporting a patient who would subsequently receive a stroke diagnosis (vs no EMS prehospital notification in those transported by EMS), and stroke symptom OTA in minutes.

The analysis included 606,369 patients (48% aged 66-85 years; 51.2% men; 69.9% White). Their median National Institutes of Health Stroke Severity (NIHSS) score was 4 (IQR, 2-10), and their median Social Deprivation Index (SDI) was 51 (IQR, 27-75).

SDI and Black race (vs White race) were not associated with differences in EMS use. County-level all-cause mortality rate (upper tercile vs lowest odds ratio [OR], 1.46; 95% CI, 1.43-1.5), female sex (OR, 1.03; 95% CI, 1.01-1.04), and increasing age (86+ vs 18-45 years OR, 1.9; 95% CI, 1.82-1.98) were among the factors associated with higher odds of EMS use. Hispanic ethnicity (OR, 0.71; 95% CI, 0.7-0.73), Asian race (OR, 0.75; 95% CI, 0.72-0.77), and rural vs urban hospital location (OR, 0.81; 95% CI, 0.79-0.83) were associated with reduced odds of EMS use.

Increased odds of EMS prehospital notification were associated with greater stroke severity (NIHSS score ≥15 vs 0-5 OR, 1.62; 95% CI, 1.59-1.65), rural vs urban hospital location (OR, 1.57; 95% CI, 1.52-1.63), and more than 30 annual thrombolytic administrations vs 30 or less (OR, 1.20; 95% CI, 1.18-1.22). SDI (upper SDI tercile vs lowest OR, 0.79; 95% CI, 0.78-0.81), Black vs White race (OR, 0.80; 95% CI, 0.78-0.82), and female sex (OR, 0.95; 95% CI, 0.94-0.97) were among the factors associated with reduced odds of EMS prehospital notification.

The unadjusted median OTA interval was 176 minutes (IQR, 64-565), which included patients arriving by EMS or private transport. At the 50th percentile (median) OTA, SDI (upper SDI tercile vs lowest, +2.56 minutes; 95% CI, 0.58-4.53), county-level all-cause mortality rate (upper tercile vs lowest, +24.25 minutes; 95% CI, 20.69-27.82), Black race (+28.21 minutes; 95% CI, 25.59-30.84), and female sex (+1.9 minutes; 95% CI, 0.41-3.39) were associated with increased OTA intervals.

The following factors were associated with decreased OTA intervals at the 50th percentile OTA:

• Increasing stroke severity (NIHSS score ≥15 vs 0-5, -28.51 minutes; 95% CI, -30.28 to -26.74)
• Atrial fibrillation (-14.71 minutes; 95% CI, -16.61 to -12.82)
• EMS use without prehospital notification (-102.48 minutes; 95% CI, -105.91 to -99.06)
• EMS use with prehospital notification (-147.6 minutes; 95% CI, -150.38 to -144.82)

Among several study limitations, GWTG-Stroke has incomplete data, and patients who present to nonstroke centers are likely underrepresented.

“Efforts to reduce place-based disparities in stroke care must address significant inequities in prehospital care of acute stroke and continue to address health inequities associated with race and ethnicity,” the study authors wrote.

Disclosure: GWTG-Stroke is sponsored, in part, by Novartis, Novo Nordisk, AstraZeneca, Bayer, Tylenol, and HCA Healthcare. Please see the original reference for a full list of disclosures.

This article originally appeared on The Cardiology Advisor