中国缺血性卒中早期静脉溶栓的现状、阻碍因素及改进策略

摘要/Abstract

摘要：

静脉应用重组组织型纤维蛋白酶原激活剂是治疗急性缺血性卒中（acute ischemic stroke, AIS）最有效的方法，且越早治疗获益越多。但全球都存在溶栓率低下，院前、院内延误明显的现象，而针对性干预可以提高溶栓率，缩短从发病至开始溶栓时间。本文结合国内外最新研究结果，对我国AIS的早期静脉溶栓现状进行总结，分析其阻碍因素，并提出我国相应的改进策略。这些措施主要包括加强针对公众和相关行业人员的卒中健康教育，实施卒中中心认证，对院前、院内各环节实施组织化和优化管理等。

文章导读： 分析我国急性缺血性卒中当前静脉溶栓现状、阻碍因素，并提出相应的改进策略。

关键词: 急性缺血性卒中; 静脉溶栓; 医疗质量

Abstract:

Intravenous recombinant tissue-type plasminogen activator (rt-PA) is proven to be the most effective method to improve outcomes for acute ischemic stroke (AIS), and the earlier use is companied with the better effects and safeties. However, the low utilization of intravenous rt-PA is a global problem, due to pre- and in-hospital delays. Meanwhile, it has been demonstrated that the thrombolysis rate can be increased and the delays can be shortened after diversity of measurements. After reviewing the advanced correspondent studies in China and developed countries, this article reviews the current state of intravenous thrombolysis for AIS in China, analyzes the barriers to stroke thrombolysis, and puts forwards the improvements in the future, including stroke health education to public and health professional, promoting stroke center certification, and optimizing the pre- and in-hospital processes and the organized administration, etc.

Key words: Acute ischemic stroke; Intravenous thrombolysis; Quality of medical care

徐安定，丁燕，李牧. 中国缺血性卒中早期静脉溶栓的现状、阻碍因素及改进策略[J]. 中国卒中杂志, 2014, 9(06): 522-528.

XU An-Ding, DING Yan, LI Mu.. The Current State, Barriers and Improving Strategies of Intravenous Thrombolysis for Acute Ischemic Stroke in China[J]. Chinese Journal of Stroke, 2014, 9(06): 522-528.

参考文献

1 Wardlaw JM, Murray V, Berge E, et al. Recombinant

tissue plasminogen activator for acute ischaemic

stroke:an updated systematic review and metaanalysis[

J]. Lancet, 2012, 379:2364-2372.

2 El Khoury R, Jung R, Nanda A, et al. Overview of key

factors in improving access to acute stroke care[J].

Neurology, 2012, 79:S26-S34.

3 Meretoja A, Keshtkaran M, Saver JL, et al. Stroke

thrombolysis:save a minute, save a day[J]. Stroke,

2014, 45:1053-1058.

4 Fonarow GC, Smith EE, Saver JL, et al. Timelines of

tissue-type plasminogen activator therapy in acute

ischemic stroke:patient characteristic, hospital factors

and outcomes associated with door-to-needles within

60 minutes[J]. Circulation, 2011, 123:750-758.

5 No authors listed. Tissue plasminogen activator for

acute ischemic stroke. The National Institute of

Neurological Disorders and Stroke rt-PA Stroke Study

Group[J]. N Engl J Med, 1995, 333:1581-1587.

6 Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis

with alteplase 3 to 4.5 hours after acute ischemic

stroke[J]. N Engl J Med, 2008, 359:1317-1329.

7 Liao XL, Wang YL, Wang CJ, et al. Thrombolysis

with intravenous recombinant tissue plasminogen

activator 3 to 4.5 h after acute ischemic stroke in

China[J]. Stroke, 2012, 43:A62.

8 Liao XL, Wang YL, Pan YS, et al. Comparison

of the eff icacy and safety of the acute st roke

patients receiving different dose intravenous tissue

plasminogen activator[J]. Stroke, 2014, 45:AWP63.

9 IST-3 collaborative group, Sandercock P, Wardlaw JM.

The benefits and harms of intravenous thrombolysis

with recombinant tissue plasminogen activator within

6 h of acute ischaemic stroke (the third international

stroke trial [IST-3]):a randomised controlled trial[J].

Lancet, 2012, 379:2352-2363.

10 Xu AD, Wang YJ, Wang DZ, et al. Consensus

statement on the use of intravenous recombinant

tissue plasminogen activator to treat acute ischemic

stroke by the Chinese Stroke Therapy Expert Panel[J].

CNS Neurosci Ther, 2013, 19:543-548.

11 Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for

the early management of patients with acute ischemic

stroke:A guideline for healthcare professionals

from American Heart Association/American Stroke

Association[J]. Stroke, 2013, 44:870-947.

12 中华医学会神经病学分会脑血管病学组急性缺血性

脑卒中诊治指南撰写组. 中国急性缺血性脑卒中诊治

指南2010[J]. 中华神经科杂志, 2010, 43:146-152.

13 Chimowitz MI. Endovascular treatment for acute

ischemic stroke--still unproven[J]. N Engl J Med,

2013, 368:952-955.

14 Eissa A, Krass I, Levi C, et al. Understanding the

reasons behind the low utilisation of thrombolysis in

stroke[J]. Australas Med J, 2013, 6:152-167.

15 中国脑卒中医疗质量评估(QUEST)协作组. 中国急性缺血性脑卒中治疗现状[J]. 中华神经科杂志, 2009,

42:223-228.

16 王伊龙, 吴敌, 周永, 等. 中国七城市卒中患者急诊溶

栓情况分析[J]. 中国卒中杂志, 2009, 4:23-26.

17 Wang Y, Liao X, Zhao X, et al. Using recombinant

tissue plasminogen activator to treat acute ischemic

stroke in China:analysis of the results from the

Chinese National Stroke Registry (CNSR)[J]. Stroke,

2011, 42:1658-1664.

18 Fo n a r ow GC, Re e ve s MJ , Smi t h EE, e t a l .

Characteristics, performance measures, and inhospital

outcomes of the first one million stroke and

transient ischemic attack admissions in get with the

guidelines-stroke[J]. Circ Cardiovasc Qual Outcomes,

2010, 3:291-302.

19 Kwan J, Hand P, Sandercock P. A systematic review of

barriers to delivery of thrombolysis for acute stroke[J].

Age Ageing, 2004, 3:116-121.

20 Mazighi M, Derex L, Amarenco P. Prehospital stroke

care:potential, pitfalls, and future[J]. Curr Opin

Neurol, 2010, 23:31-35.

21 Higashida R, Alberts MJ, Alexander DN, et al.

Interactions within stroke systems of care:a policy

statement from the American Heart Association/

American St roke Association[J]. St roke, 2013,

44:2961-2984.

22 Mosley I, Nicol M, Donnan G, et al. Stroke symptoms

and the decision to call for ambulance[J]. Stroke, 2007,

38:361-366.

23 Anderson BE, Rafferty AP, Lyon-Callo S, et al.

Knowledge of tissue plasminogen activator for acute

stroke among Michigan adults[J]. Stroke, 2009,

40:2564-2567.

24 孙海欣, 王文志, 江滨, 等. 中国四城市社区居民卒

中知识水平相关因素分析[J]. 中国卒中杂志, 2012,

7:618-625.

25 Zeng Y, He GP, Yi GH, et al. Knowledge of stroke

warning signs and risk factors among patients with

previous stroke or TIA in China[J]. J Clin Nurs, 2012,

21:2886-2895.

26 Yang J, Zheng M, Cheng S, et al. Knowledge of

Stroke Symptoms and Treatment among Community

Residents in Western Urban China[J]. J Stroke

Cerebrovasc Dis, 2014, 23:1216-1224.

27 毕齐, 张茁, 张薇薇, 等. 北京等15个城市脑卒中患

者院前时间及影响因素研究[J]. 中华流行病学杂志,

2006, 27:996-999.

28 Jin H, Zhu S, Wei JW, et al. Factors associated with

prehospital delays in the presentation of acute stroke

in urban China[J]. Stroke, 2012, 43:362-370.

29 Chen S, Sun H, Zhao X, et al. Effects of comprehensive

education protocol in decreasing pre-hospital stroke

delay among Chinese urban community population[J].

Neurol Res, 2013, 35:522-528.

30 Fa s sb e nd e r K, Ba lu c a n i C, Wa l t e r S, e t a l .

Streamlining of prehospital stroke management:the

golden hour[J]. Lancet Neurol, 2013, 12:585-596.

31 Engelter ST, Gostynski M, Papa S, et al. Barriers

to stroke thrombolysis in a geographically defined

population[J]. Cerebrovasc Dis, 2007, 23:211-215.

32 Wang YL, Wu D, Zhao XQ, et al. Hospital resources

for urokinase/recombinant tissue-type plasminogen

activator therapy for acute stroke in Beijing[J]. Surg

Neurol, 2009, 72 Suppl 1:S2-S7.

33 Uenaka T, Yoneda Y, Yamamoto S, et al. Brain

imaging modality before systemic thrombolysis for

ischemic stroke within three hours[J]. Eur Neurol,

2010, 64:241-245.

34 Ford AL, Williams JA, Spencer M, et al. Reducing

d o o r- t o - n e e d l e t ime s u s i n g To y o t a ' s l e a n

manufacturing principles and value stream analysis[J].

Stroke, 2012, 43:3395-3398.

35 Fonarow GC, Zhao X, Smith EE, et al. Improving

door-to-needle times in acute ischemic stroke:principal

results from the Target:Stroke Initiative[EB/OL].

(2014-02-14)[2014-04-16]. http://my.americanheart.

org/idc/groups/ahamah-public/@wcm/@sop/@scon/

documents/downloadable/ucm_460266.pdf.

36 Coot e S, Frost T, Singhal S, et al. Di re ct to

CT:overcoming barriers to reduce door to needle time

in acute stroke patients[J]. Stroke, 2014, 45:AWP177.

37 赵颖, 辛秀峰, 徐安定, 等. 关键医疗指标监控对提高

缺血性脑血管病临床医疗质量的作用[J]. 暨南大学学

报, 2013, 34:186-190.

38 中国医院协会. 单病种质量管理手册[M]. 2版. 北京:

科学技术文献出版社, 2010:142-197.

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