Prior treatment with NOACs safe among patients receiving IV alteplase for acute ischemic stroke

In a significant development, a groundbreaking study revealed that compared to no anticoagulant treatment, prior NOAC treatment did not associate with a heightened risk of intracranial hemorrhage, major bleeding, or mortality in patients undergoing intravenous alteplase for acute ischemic stroke. This nationwide study results were published in the journal JAMA Network. 

Present guidelines do not suggest the use of intravenous alteplase therapy for the treatment of acute ischemic stroke in patients previously treated with non–vitamin K antagonist oral anticoagulants (NOACs). Hence Taiwanese researchers conducted a nationwide cohort study to shed light on the safety of intravenous alteplase therapy for acute ischemic stroke in individuals who were previously treated with non–vitamin K antagonist oral anticoagulants (NOACs). The study, utilizing data from Taiwan’s National Health Insurance Research Database, spanned from January 2011 to November 2020 and involved the meticulous examination of 7483 patients who underwent alteplase treatment for acute ischemic stroke.

The primary focus of the study was to evaluate the potential risks of bleeding and mortality associated with alteplase treatment in patients who had received NOACs before their stroke, in comparison to those who had not been treated with NOACs. This comes at a critical juncture as current guidelines caution against intravenous alteplase therapy in such cases.

The research, designed as a population-based cohort study, employed rigorous methods to assess outcomes. Patients who received NOAC treatment within two days prior to their stroke were compared with those receiving either no anticoagulant treatment or warfarin treatment.

The study's findings:

• Contrary to concerns, patients treated with NOACs did not demonstrate a significantly higher risk of intracranial hemorrhage, major bleeding events, or in-hospital mortality compared to those without anticoagulant treatment.
• The results were obtained through propensity score matching to control potential confounding variables and logistic regression to estimate odds ratios for outcome events.
• Furthermore, the study delved into a meta-analysis, incorporating its results with those from previous studies.
• The consistency of findings across various studies adds weight to the conclusion that patients treated with NOACs prior to their stroke do not face an elevated risk when undergoing intravenous alteplase therapy.

This reassurance is particularly significant given the challenges posed by acute ischemic stroke and the complexities introduced by anticoagulant treatments. The research not only addresses a critical gap in current medical knowledge but also provides clinicians with valuable insights when making treatment decisions for stroke patients with a history of NOAC use. As the medical community continues to grapple with the long-term consequences of COVID-19, studies like these offer tangible progress toward refining and personalizing treatment approaches for individuals with post-viral complications, ensuring that patient care remains at the forefront of medical advancements.

Further reading: Tsai T, Liu Y, Huang W, et al. Risk of Bleeding Following Non–Vitamin K Antagonist Oral Anticoagulant Use in Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA Intern Med. Published online November 20, 2023. doi: 10.1001/jamainternmed.2023.6160