Factors Associated with Pre-hospital Delay in the Presentation of Acute Ischemic Stroke
in China

Abstract

Abstract:

Objective To explore the factors associated with pre-hospital delay of acute ischemic stroke. Methods Data from the China National Stroke Registry (CNSR) were used to identify patients who were consecutively admitted to 132 urban hospitals across China with acute stroke between September 2007 and August 2008. According to three hours as cut-off point of the onset-door time, factors associated with delayed presentation to hospital were evaluated. Univariate and multivariate analyses were performed to analyze relationships between patient characteristics and delayed presentation. Results Of 10 503 acute ischemic stroke patients entered into the CNSR, only 2267 patients (21.58%) arrived into the hospital within 3 hours. There are some factors that could shorten presentation to hospital such as the aged, transferred by ambulance, history of drinking, coronary heart disease, atrial fibrillation, and first symptom of unconsciousness. Factors associated with prehospital delay are as follows: living alone, self-payment for medical insurance, finding the symptom awake, modified Rankin Scale (mRS) score of pre-stroke more than 2, history of hypertension, diabetes, first symptom of aphasia and defect of field vision. Conclusion The phenomenon of pre-hospital delay of acute ischemic stroke in China is still serious. We should impart enough knowledge of stroke to people and encourage them to use the emergency system, in order to increase the awareness rate and improve treatment and prognosis.

Key words: Ischemic stroke; Pre-hospital delay; Emergency system; Living alone

摘要：

目的分析我国急性脑梗死患者院前延误的影响因素。方法中国国家卒中登记数据库于2007年9月到2008年8月连续收集来自全国各地132家二级和三级医院的急性卒中住院患者。本研究利用该数据库中的患者信息，以发病至到院时间大于3 h为院前延误，通过单因素和多因素Logistic回归分析，探讨急性缺血性卒中患者院前延误的影响因素。结果本研究对来自中国国家卒中登记数据库的10 503例急性脑梗死患者进行院前延误影响因素的分析，结果发现仅有21.58%的患者（n =2267）在发病3 h内到达医院。导致院前延误时间缩短的因素有：老龄［调整后的比值比（odds ratio，OR）0.992，95%可信区间（confidence interval， CI）0.988～0.997］、使用急救车到达医院（调整后的OR 0.340，95%CI 0.300～0.384）、饮酒史（调整后的OR 0.895，95%CI 0.802～0.999）、冠状动脉粥样硬化性心脏病史（调整后的OR 0.786， 95%CI 0.684～0.903）、心房颤动病史（调整后的OR 0.535，95%CI 0.452～0.635）、首发症状为意识障碍（调整后的OR 0.660，95%CI 0.561～0.776）。导致院前延误时间延长的因素：单独居住（调整后的OR 1.760，95%CI 1.307～2.371）、自费医疗（调整后的OR 1.235，95%CI 1.081～1.411）、睡醒时发现症状（调整后的OR 1.678，95%C I 1.489～1.891）、发病前改良R an ki n量表（m o d i fi e d Rankin Scale，mRS）评分≥2分（调整后的OR 1.445，95%CI 1.207～1.730）、高血压病史（调整后的 OR 1.114，95%CI 1.004～1.238）、糖尿病病史（调整后的OR 1.141，95%CI 1.006～1.293）、首发症状为失语（调整后的OR 1.380，95%CI 1.239～1.536）、首发症状为视野缺损（调整后的OR 1.458， 95%CI 1.036～2.051）。结论我国脑梗死患者的院前延误现象比较严重，提高公众对卒中的认识，加强院前急救系统的使用，早期发现症状，尽可能使用救护系统，缩短院前延误时间，使患者得到及时有效的诊治。

关键词: 脑梗死; 院前延误; 急救系统; 单独居住

SONG Yan-Li, LIU Gai-Fen, WANG Yan-Yun, et al.. Factors Associated with Pre-hospital Delay in the Presentation of Acute Ischemic Stroke
in China[J]. Chinese Journal of Stroke, 2014, 9(09): 736-742.

宋彦丽，刘改芬，王艳云，等. 中国急性脑梗死院前延误影响因素分析[J]. 中国卒中杂志, 2014, 9(09): 736-742.

References

1 Johnston SC, Mendis S, Mathers CD. Global variation

in stroke burden and mor tality:estimates from

monitoring, surveillance, and modelling[J]. Lancet

Neurol, 2009, 8:345-354.

2 Liu L, Wang D, Wong KS, et al. Stroke and stroke

care in China:huge burden, significant workload, and

a national priority[J]. Stroke, 2011, 42:3651-3654.

3 Liu M, Wu B, Wang WZ, et al. Stroke in China:

e pidemiolog y, pr eve nt ion , a nd ma nageme nt

strategies[J]. Lancet Neurol, 2007, 6:456-464.

4 Group IC. 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 Neurol, 2012, 379:2352-

2363.

5 Wardlaw J, Murray V, Berge E. Recombinant tissue

plasminogen activator for acute ischaemic stroke:an

updated systematic review and meta-analysis[J].

Lancet Neurol, 2012, 379:2364-2372.

6 Lees KR, Bluhmki E, von Kummer R, et al. Time

to treatment with intravenous alteplase and outcome

in stroke:an updated pooled analysis of ECASS,

ATLANTIS, NINDS, and EPITHET trials[J]. Lancet,

2010, 375:1695-1703.

7 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.

8 Hong KS, Bang OY, Kim JS, et al. Stroke statistics in

Korea:Part II stroke awareness and acute stroke care,

a report from the Korean Stroke Society and Clinical

Research Center for stroke[J]. J Stroke, 2013, 15:67-77.

9 Reeves MJ, Arora S, Broderick JP, et al. Acute stroke

care in the US:results from 4 pilot prototypes of the

Paul Coverdell National Acute Stroke Registry[J].

Stroke, 2005, 36:1232-1240.

10 Kleindor fer D, Kissela B, Schneider A, et al.

Eligibility for recombinant tissue plasminogen

activator in acute ischemic stroke:a population-based

study[J]. Stroke, 2004, 35:e27-e29.

11 Wang Y, Cui L, Ji X, et al. The China National Stroke

Registry for patients with acute cerebrovascular

events:design, rationale, and baseline patient

characteristics[J]. Int J Stroke, 2011, 6:355-361.

12 Aho K, Harmsen P, Hatano S, et al. Cerebrovascular

dise a se i n the commu nit y:re sult s of a WHO

collaborative study[J]. Bull World Health Organ, 1980,

58:113-130.

13 Evenson KR, Foraker RE, Mor ris DL, et al. A

comprehensive review of prehospital and in-hospital

delay times in acute stroke care[J]. Int J Stroke, 2009,

4:187-199.

14 Maestroni A, Mandelli C, Manganaro D, et al. Factors

influencing delay in presentation for acute stroke in an

emergency department in Milan, Italy[J]. Emerg Med

J, 2008, 25:340-345.

15 Mor r i s DL, Ros amond W, Ma dde n K, e t a l .

Prehospital and emergency department delays after

acute stroke:the Genentech Stroke Presentation

Survey[J]. Stroke, 2000, 31:2585-2590.

16 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.

17 La cy CR, Su h DC, Bueno M, et al. Delay in

presentation and evaluation for acute stroke:Stroke

Time Regist r y for Out come s Knowledge and

Epidemiology[J]. Stroke, 2001, 32:63-69.

18 傅瑜, 樊东升, 张远锦, 等. 急性脑卒中的就诊延迟因

素研究[J]. 北京大学学报(医学版), 2003, 35:299-302.

19 Derex L, Adeleine P, Nighoghossian N, et al. Factors

influencing early admission in a French stroke unit[J].

Stroke, 2002, 33:153-159.

20 Faiz KW, Sundseth A, Thommessen B, et al. Factors

related to decision delay in acute stroke[J]. J Stroke

Cerebrovasc Dis, 2014, 23:534-539.

21 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.

22 孙海欣, 王文志. 卒中患者就诊延误的影响因素及其

干预措施[J]. 中国卒中杂志, 2010, 5:758-762.

23 Ragoschke-Schumm A, Walter S, Haass A, et al.

Translation of the 'time is brain' concept into clinical

practice:focus on prehospital stroke management[J].

Int J Stroke, 2014, 9:333-340.

24 Moser DK, Kimble LP, Alberts MJ, et al. Reducing

delay in seeking treatment by patients with acute

coronary syndrome and stroke:a scientific statement

from the American Hear t Association Council

on cardiovascular nursing and stroke council[J].

Circulation, 2006, 114:168-182.

25 Wang L, Chao Y, Zhao X, et al. Factors associated

with delayed presentation in patients with TIA and

minor stroke in China:analysis of data from the China

National Stroke Registry (CNSR)[J]. Neurol Res, 2013,

35:517-521.

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