Stroke: Is lysis safe after administration of oral anticoagulants?

Large international cohort study finds «insufficient evidence of excessive harm» from this off-label application.

Knowledge

• Intravenous thrombolysis (IVT) appeared in patients with ischemic stroke who had occurred in the last 48  hours of direct oral anticoagulant nbsp (DOAC) were not associated with an excessive risk of symptomatic intracranial haemorrhage.

Why this matters

• US-American and European Guidelines discourage IVT in this patient population due to concerns about bleeding.

Study design

• International retrospective cohort study with consecutive adult patients with acute ischemic stroke treated with IVT, with or without thrombectomy:
  • 832 with recent DOAC use (confirmed intake ≤ 48  hours before IVT)
  • 32.375 without anticoagulant administration
• Main result: symptomatic intracranial hemorrhage within 36  hours after  IVT (worsening by ≥ 4  Points on the NIH  stroke scale, which is due to radiologically evident intracranial hemorrhage).
• Funding: Bangerter-Rhyner Foundation

• 832 with recent DOAC use (confirmed intake ≤ 48  hours before IVT)
• 32.375 without anticoagulant administration

Key findings

• Symptomatic intracranial haemorrhage occurred in 2.5 % of the DOAC group and 4.1 % of the noncoagulation group.
• Overall, the difference corresponded to a 43 % lower adjusted probability in patients with recent DOAC use (p = 0.02).
• The probability was lower for those who received treatment to cancel the DOAC before the IVT by  64 % lower (p = 0.16), for those whose DOAC values were determined before the IVT by  44 % lower (p = 0.14) and for those who did not receive any of these selection strategies. um 34 % less (p = 0,20).
• In patients with plasma detectable DOAC concentrations or in patients with <12  hours before taking IVT, a similar pattern was observed (43 % lower probability; p = 0.23).
• Compared to control patients without anticoagulation, patients with recent DOAC use had an um 18 % higher probability of hemorrhagic transformation in imaging within 36  hours on (p = 0,14), but also an um 13 % higher probability of functional independence after 90  days (p = 0,20).

Expert comment

• In a Editorial writes Eva A.Mistry, MBBS, MSCI, University of Cincinnati, Cincinnati, Ohio, that «the study provides preliminary time-critical data suggesting thrombolysis (primarily through the use of alteplase) in patients with [acute ischemic stroke] who have recently used a DOAC and present within the standard thrombolysis window. Despite the limitations of the study design and the population enrolled, these data can be used by physicians to make individual thrombolysis decisions regarding patients with recent DOAC use.»

Restrictions

• The results may have been affected by selection bias and other confounding factors.
• The dose of IVT administered varied between centers.
• The test strength of the study was probably insufficient for analysis of some subgroups.

This full text is unfortunately reserved for medical professionals

You have reached the maximum number of articles for unregistered visitors