Journal
LANCET
Volume 379, Issue 9834, Pages 2352-2363Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/S0140-6736(12)60768-5
Keywords
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Categories
Funding
- UK Medical Research Council
- Health Foundation UK
- Stroke Association UK
- Research Council of Norway
- Arbetsmarknadens Partners Forsakringsbolag (AFA) Insurances Sweden
- Swedish Heart Lung Fund
- Foundation of Marianne and Marcus Wallenberg
- Polish Ministry of Science and Education
- Australian Heart Foundation
- Australian National Health and Medical Research Council (NHMRC)
- Swiss National Research Foundation
- Swiss Heart Foundation
- Assessorato alla Sanita
- Regione dell'Umbria, Italy
- Danube University
- Boehringer Ingelheim
- Sanofi Synthlabo Aventis
- Hoffman La Roche
- Novo Nordisk
- UK Research Councils Joint Research Equipment Initiative
- UK MRC [G0400069, EME 09-800-15]
- AFA Insurances (Sweden)
- Stockholm County Council
- Karolinska Institute (Sweden)
- Government of Poland [2PO5B10928]
- Australian Heart Foundation [G 04S 1638]
- Australian NHMRC [457343]
- Foundation for health and cardio-/neurovascular research, Basel, Switzerland
- Danube University, Krems, Austria
- NIHR Stroke Research Network
- NHS Research Scotland, through the Scottish Stroke Research Network
- National Institute for Social Care and Health Research Clinical Research Centre
- Scottish Funding Council
- Chief Scientist Office of the Scottish Executive
- Chest Heart and Stroke Scotland
- DesAcc
- University of Edinburgh
- Danderyd Hospital RD Department
- Oslo University Hospital
- Dalhousie University
- NIHR through the UK Stroke Research Network
- Medical Research Council [MC_G1002455, G0902303, G0400069, G0800803, G0700704B] Funding Source: researchfish
- MRC [G0400069, G0902303, G0800803, MC_G1002455] Funding Source: UKRI
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Background Thrombolysis is of net benefit in patients with acute ischaemic stroke, who are younger than 80 years of age and are treated within 4.5 h of onset. The third International Stroke Trial (IST-3) sought to determine whether a wider range of patients might benefit up to 6 h from stroke onset. Methods In this international, multicentre, randomised, open-treatment trial, patients were allocated to 0.9 mg/kg intravenous recombinant tissue plasminogen activator (rt-PA) or to control. The primary analysis was of the proportion of patients alive and independent, as defined by an Oxford Handicap Score (OHS) of 0-2 at 6 months. The study is registered, ISRCTN25765518. Findings 3035 patients were enrolled by 156 hospitals in 12 countries. All of these patients were included in the analyses (1515 in the rt-PA group vs 1520 in the control group), of whom 1617 (53%) were older than 80 years of age. At 6 months, 554 (37%) patients in the rt-PA group versus 534 (35%) in the control group were alive and independent (OHS 0-2; adjusted odds ratio [OR] 1.13, 95% CI 0.95-1.35, p=0.181; a non-significant absolute increase of 14/1000, 95% CI -20 to 48). An ordinal analysis showed a significant shift in OHS scores; common OR 1.27 (95% CI 1.10-1.47, p=0.001). Fatal or non-fatal symptomatic intracranial haemorrhage within 7 days occurred in 104 (7%) patients in the rt-PA group versus 16 (1%) in the control group (adjusted OR 6.94, 95% CI 4.07-11.8; absolute excess 58/1000, 95% CI 44-72). More deaths occurred within 7 days in the rt-PA group (163 [11%]) than in the control group (107 [7%], adjusted OR 1.60, 95% CI 1.22-2.08, p=0.001; absolute increase 37/1000, 95% CI 17-57), but between 7 days and 6 months there were fewer deaths in the rt-PA group than in the control group, so that by 6 months, similar numbers, in total, had died (408 [27%] in the rt-PA group vs 407 [27%] in the control group). Interpretation For the types of patient recruited in IST-3, despite the early hazards, thrombolysis within 6 h improved functional outcome. Benefit did not seem to be diminished in elderly patients.
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