No harm of intravenous thrombolysis in stroke patients with recent use of DOACs: JAMA

The use of off-label intravenous thrombolysis (IVT) in stroke patients who had taken a direct oral anticoagulant (DOACs) within the previous 48 hours did not impart excess harm, says Journal of American Medical Association.

International guidelines strongly recommend avoiding IVT in ischemic stroke patients who have recently taken direct oral anticoagulants. This prompted Thomas Meinel and peers to determine the risk of symptomatic intracranial hemorrhage (sICH) associated with the use of IVT in patients who recently used DOACs.

Data from January 2008 to December 2021 around 64 primary and comprehensive stroke centers in Europe, Asia, Australia, and New Zealand were taken for this retrospective study and ischemic stroke patients undergoing IVT (with or without thrombectomy) were included. Patients who have last taken a DOAC more than 48 hours before the stroke onset were excluded from study. A total of 832 patients with recent DOAC use were compared with 32,375 controls with no recent DOAC use. The primary outcome of the study was SICH within his 36 hours of IVT - worsening by at least 4 points on the National Institutes of Health Stroke Scale and also radiographically evident intracranial hemorrhage.

The highlights of the study were:

The study enrolled 33,207 patients where 14,458 (43.5%) were female from 62-80 years of age.

Of the 832 patients taking DOAC, 355 (42.7%) received IVT without measuring plasma levels of DOAC or reversal treatment, 252 (30.3%) received DOAC reversal prior to IVT (all idarucizumab) and 225 (27.0%) had DOAC-level measurements.

The unadjusted SICH rate was 2.5% in patients taking DOACs compared to 4.1% patients taking no anticoagulants.

Recent DOAC use was linked to a lower likelihood of SICH after IVT compared with no anticoagulation. This findings were consistent in patients with detectable plasma levels or recent exposure across different selection strategies and across sensitivity analyzes.

Source:

Meinel, T. R., Wilson, D., Gensicke, H., Scheitz, J. F., Ringleb, P., Goganau, I., Kaesmacher, J., Bae, H.-J., Kim, D. Y., Kermer, P., Suzuki, K., Kimura, K., Macha, K., Koga, M., Wada, S., Altersberger, V., Salerno, A., Palanikumar, L., … Zini, A. (2023). Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants. In JAMA Neurology. American Medical Association (AMA). https://doi.org/10.1001/jamaneurol.2022.4782