Ethnicity and thrombolysis in ischemic stroke : a hospital based study in

Background: Ethnic differences have been reported with regard to several medical therapies. The aim of this study was to investigate the relation between ethnicity and thrombolysis in stroke patients. Methods: Retrospective single-centre study. Patients admitted with an ischemic stroke between 2003 and 2008 were included. Ethnicity was determined by self-identification and stratified into white and non-white (all other ethnicities). The main outcome measure was the difference in thrombolysis rate between white and non-white patients. Logistic regression analysis was used to identify potential confounders of the relation between ethnicity and thrombolysis. Results: 510 patients were included, 392 (77%) white and 118 (23%) non-white. Non-white patients were younger (median 69 vs. 60 years, p < 0.001), had a higher blood pressure at admission (median systolic 150 vs. 160 mmHg, p = 0.02) and a lower stroke severity (median NIHSS 5 vs. 4, p = 0.04). Non-white patients were significantly less often treated with thrombolysis compared to white patients (odds ratio 0.34, 95% CI 0.17-0.71), which was partly explained by a later arrival at the hospital. After adjustment for potential confounders (late arrival, age, blood pressure above upper limit for thrombolysis, and oral anticoagulation use), a trend towards a lower thrombolysis rate in non-whites remained (adjusted odds ratio 0.38, 95% CI 0.13 to 1.16). Conclusions: Non-white stroke patients less often received thrombolysis than white patients, partly as a result of a delay in presentation. In this single centre study, potential bias due to hospital differences or insurance status could be ruled out as a cause. The magnitude of the difference is worrisome and requires further investigation. Modifiable causes, such as patient delay, awareness of stroke symptoms, language barriers and treatment of cardiovascular risk factors, should be addressed specifically in these ethnic groups in future stroke campaigns. Background Despite its proven efficacy, only a minority of patients with an acute ischemic stroke are treated with intravenous thrombolysis [1-3]. A delay in hospital presentation is the most important reason why this treatment is withheld from stroke patients [4,5]. Other factors associated with not receiving thrombolysis are female gender, older age, improving or too mild neurological deficit and admittance to hospitals that are non-academic, small, or located in areas with a low population density [6-9]. Various studies have shown consistently that the level of medical care is lower in ethnic minorities. Examples are reperfusion therapy for myocardial infarction [10], treatment of hypertension [11], and carotid endarterectomy [12]. Two studies have investigated the relation between ethnicity and thrombolysis for acute ischemic stroke in North-America [13,14]. Both found that black patients were significantly less likely to undergo thrombolysis than white patients. The magnitude of the difference varied considerably between the studies. Furthermore, because both were multi-centre studies, hospital related factors, in addition to ethnicity, may have attributed to the difference in thrombolysis rate. The aim of the present study was to investigate the relation between ethnicity and thrombolysis in a single academic hospital with a multi-ethnic caption area. * Correspondence: p.j.nederkoorn@amc.uva. nl † Contributed equally Department of Neurology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands Coutinho et al. BMC Neurology 2011, 11:81 http://www.biomedcentral. com/1471-2377/11/81 © 2011 Coutinho et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.