The ‘three-hour effect’ constitutes procrastination in thrombolytic stroke treatment

Dear Editor:

It was with great interest that we read the study by Iglesias Mohedano et al.¹ addressing the factors associated with in-hospital delays in administering intravenous thrombolysis to patients with acute ischaemic stroke in a tertiary hospital. Curiously enough, one of the crucial factors associated with treatment delay in the multivariate analysis was onset-to-door time: the sooner patients arrive at the hospital, the longer they have to wait to receive thrombolysis once the CT study has been completed. The authors cite 2 articles dated 2011 and 2012 mentioning this phenomenon, which they call the ‘3-hour effect’.^2,3 However, this 3-hour effect is a function of the therapeutic window and should now be called the ‘4.5-hour effect’, or the ‘6/8-hour effect’ in the case of endovascular revascularisation.

In 2005, we proposed the term ‘procrastination’, that is, putting off a task unnecessarily and with no justification,⁴ a very typical practice possibly resulting from laziness, which is probably not the case here, or reflecting the complexity and risks associated with a pending decision, as occurs with thrombolysis. Informally alerting our neurologists to the dangers of procrastination led to significant improvements, as we found some months later.⁵ However, not all tertiary hospitals seem to be aware of procrastination and this faulty practice is still frequent: CT-to-needle time was longer in patients with shorter onset-to-door time, at least until the publication of the study by Iglesias Mohedano et al.¹ Specific emphasis should be placed on avoiding unnecessary delays, which can still be observed even after 20 years of thrombolytic stroke treatment. Even for patients within the therapeutic window, the sooner the treatment, the better.

Conflicts of interest

The authors have no conflicts of interest to declare.