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Alam K, Khan AN, Fatima A, Haseeb A, Jaffar D, Mussarat A, Amir M, Rana MO, Saeed H, Asmar A. Assessing mortality and safety of IV thrombolysis in ischemic stroke patients on direct oral anticoagulants (DOACs): A systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 246:108523. [PMID: 39278007 DOI: 10.1016/j.clineuro.2024.108523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 08/30/2024] [Accepted: 08/31/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is considered a standard reperfusion therapy for acute ischemic stroke (AIS) patients presenting within 4.5 hours of the last known well (LKW). Current guidelines contraindicate the use of IVT in patients within the window who are on Direct Oral Anticoagulants (DOACs) and took their last dose within 48 hours of presentation, due to a risk of symptomatic intracranial hemorrhage (sICH). OBJECTIVE To assess the safety of IVT as management of AIS in patients who take DOACs. METHODS A thorough literature search of four databases (PubMed, Scopus, Medline, Google Scholar, Web of science and ScienceDirect) was done from inception until May 2023. Double-arm studies that reported outcomes of mortality, sICH, and mRS scores were selected. Results from these studies were presented as odds ratios (ORs) with 95 % confidence intervals (CIs) and were pooled using a random-effects model. RESULTS Four eligible studies were included with a total of 238,425 stroke patients who underwent IVT (3330 in the DOAC arm and 235,217 in the placebo arm). The group with prior DOAC intake showed a significant decrease in sICH development and an increase in functional independence at 90 days compared to the control group. No significant association was seen between prior DOAC use and any serious alteplase-related complication within 36 hours, serious systemic or life-threatening hemorrhage within 36 hours, mortality within 3 months, or mRS score at 3 months. CONCLUSION The pooled analysis suggests that IVT is a safe management option for acute ischemic stroke in patients with DOAC intake before symptom onset without an increased risk of serious adverse events.
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Affiliation(s)
- Khadija Alam
- Liaquat National Hospital and Medical College, Karachi, Pakistan.
| | | | - Afia Fatima
- Jinnah Sindh Medical university, Karachi, Pakistan
| | - Abdul Haseeb
- Jinnah Sindh Medical university, Karachi, Pakistan
| | - Duaa Jaffar
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Maryam Amir
- Jinnah Sindh Medical university, Karachi, Pakistan
| | | | - Hamid Saeed
- Dow University of Health Sciences, Karachi, Pakistan
| | - Abyaz Asmar
- Department of Neurology, Houston Methodist Hospital, Houston, TX, USA
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Monjazeb S, Chang HV, Lyden PD. Before, during, and after: An Argument for Safety and Improved Outcome of Thrombolysis in Acute Ischemic Stroke with Direct Oral Anticoagulant Treatment. Ann Neurol 2024. [PMID: 39258443 DOI: 10.1002/ana.27058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 08/01/2024] [Accepted: 08/03/2024] [Indexed: 09/12/2024]
Abstract
Direct oral anticoagulants are the primary stroke prevention option in patients with atrial fibrillation. Anticoagulant use before stroke, however, might inhibit clinician comfort with thrombolysis if a stroke does occur. Resuming anticoagulants after ischemic stroke is also problematic for fear of hemorrhage. We describe extensive literature showing that thrombolysis is safe after stroke with direct anticoagulant use. Early reinstitution of direct anticoagulant treatment is associated with lower risk of embolic recurrence and lower hemorrhage risk. The use of direct anticoagulants before, during, and after thrombolysis appears to be safe and is likely to promote improved outcomes after ischemic stroke. ANN NEUROL 2024.
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Affiliation(s)
- Sanaz Monjazeb
- Department of Neurology, Zilkha Neurogenetic Institute of the Keck School of Medicine, Los Angeles, CA, USA
| | - Heather V Chang
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute of the Keck School of Medicine, Los Angeles, CA, USA
| | - Patrick D Lyden
- Department of Neurology, Zilkha Neurogenetic Institute of the Keck School of Medicine, Los Angeles, CA, USA
- Department of Physiology and Neuroscience, Zilkha Neurogenetic Institute of the Keck School of Medicine, Los Angeles, CA, USA
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Frol S, Pretnar Oblak J, Kermer P, Ntaios G, Papanagiotou P, Šabovič M. Higher efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants-A new relevant hypothesis. Front Neurol 2024; 15:1458697. [PMID: 39309266 PMCID: PMC11412810 DOI: 10.3389/fneur.2024.1458697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/27/2024] [Indexed: 09/25/2024] Open
Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Pawel Kermer
- Department of Neurology, Nordwest-Krankenhaus Sanderbusch, Friesland Kliniken GmbH, Sande, Germany
- University Medical Center Göttingen, Göttingen, Germany
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Panagiotis Papanagiotou
- Clinic of Diagnostic and Interventional Neuroradiology, Klinikum Bremen Mitte, Bremen, Germany
- Department of Radiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Mišo Šabovič
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Vascular Disorders, University Medical Center Ljubljana, Ljubljana, Slovenia
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Meinel TR, Paramasivan NK, Menon BK, Fischer U, Seiffge DJ. Thrombolysis for Ischemic Stroke Despite Recent Ingestion of Direct Oral Anticoagulants - A Growing Dilemma Also in India. Ann Indian Acad Neurol 2024; 27:345-351. [PMID: 39196805 PMCID: PMC11418782 DOI: 10.4103/aian.aian_524_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 08/30/2024] Open
Abstract
The administration of intravenous thrombolysis (IVT) for patients with acute ischemic stroke who have recently ingested direct oral anticoagulants (DOACs) presents a clinical challenge due to the perceived increased risk of intracranial hemorrhage (ICH). Traditional guidelines from the US and European authorities advise against IVT within 48 h of last DOAC ingestion, unless specific coagulation tests indicate safety. However, emerging observational studies suggest that IVT might be safe in selected patients. A US stroke registry study and a global multicenter cohort study both reported no significant increase in symptomatic ICH among patients on DOACs compared to those not on anticoagulants. A systematic review of all published observational studies further supported these findings, showing comparable bleeding rates and functional outcomes in DOAC-treated patients. Reversal agents like idarucizumab for dabigatran have demonstrated potential in facilitating safer IVT administration, though logistical and cost-related barriers limit their widespread use. The variability in global guidelines reflects differing approaches to risk assessment and resource availability, highlighting the need for individualized treatment decisions. In India, the increasing prevalence of atrial fibrillation and stroke as well as prescription of DOACs necessitate adapted guidelines that consider local health-care infrastructure. Despite the promising observational data, the lack of randomized controlled trials underscores the need for further research to establish robust evidence for IVT use in this context. Collaborative international efforts and inclusion of diverse patient populations in future studies will be crucial to refine treatment protocols and improve outcomes for stroke patients on DOACs.
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Affiliation(s)
- Thomas R. Meinel
- Department of Neurology and Stroke Research Center, Bern Inselspital, University of Bern, Bern, Switzerland
| | | | - Bijoy K. Menon
- Department of Clinical Neurosciences, Radiology and Community Health Sciences, Cumming School of Medicine and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Urs Fischer
- Department of Neurology and Stroke Research Center, Bern Inselspital, University of Bern, Bern, Switzerland
| | - David J. Seiffge
- Department of Neurology and Stroke Research Center, Bern Inselspital, University of Bern, Bern, Switzerland
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Tsai TY, Liu YC, Huang WT, Tu YK, Qiu SQ, Noor S, Huang YC, Chou EH, Lai ECC, Huang HK. Risk of Bleeding Following Non-Vitamin K Antagonist Oral Anticoagulant Use in Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA Intern Med 2024; 184:37-45. [PMID: 37983035 PMCID: PMC10660269 DOI: 10.1001/jamainternmed.2023.6160] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/25/2023] [Indexed: 11/21/2023]
Abstract
Importance Current guidelines advise against intravenous alteplase therapy for treatment of acute ischemic stroke in patients previously treated with non-vitamin K antagonist oral anticoagulants (NOACs). Objective To evaluate the risk of bleeding and mortality after alteplase treatment for acute ischemic stroke among patients treated with NOACs compared to those not treated with NOACs. Design, Setting, and Participants This nationwide, population-based cohort study was conducted in Taiwan using data from Taiwan's National Health Insurance Research Database from January 2011 through November 2020 and included 7483 patients treated with alteplase for acute ischemic stroke. A meta-analysis incorporating the results of the study with those of previous studies was performed, and the review protocol was prospectively registered with PROSPERO. Exposures NOAC treatment within 2 days prior to stroke, compared to either no anticoagulant treatment or warfarin treatment. Main Outcomes and Measures The primary outcome was intracranial hemorrhage after intravenous alteplase during the index hospitalization (the hospitalization subsequent to alteplase administration). Secondary outcomes were major bleeding events and mortality during the index hospitalization. Propensity score matching was used to control potential confounders. Logistic regression was used to estimate the odds ratio (OR) of outcome events. Meta-analysis was performed using a random-effects model. Results Of the 7483 included patients (mean [SD] age, 67.4 [12.7] years; 2908 [38.9%] female individuals and 4575 [61.1%] male individuals), 91 (1.2%), 182 (2.4%), and 7210 (96.4%) received NOACs, warfarin, and no anticoagulants prior to their stroke, respectively. Compared to patients who were not treated with anticoagulants, those treated with NOACs did not have significantly higher risks of intracranial hemorrhage (risk difference [RD], 2.47% [95% CI, -4.23% to 9.17%]; OR, 1.37 [95% CI, 0.62-3.03]), major bleeding (RD, 4.95% [95% CI, -2.56% to 12.45%]; OR, 1.69 [95% CI, 0.83-3.45]), or in-hospital mortality (RD, -4.95% [95% CI, -10.11% to 0.22%]; OR, 0.45 [95% CI, 0.15-1.29]) in the propensity score-matched analyses. Furthermore, the risks of bleeding and mortality were not significantly different between patients treated with NOACs and those treated with warfarin. Similar results were obtained in the meta-analysis. Conclusions and Relevance In this cohort study with meta-analysis, compared to no treatment with anticoagulants, treatment with NOACs prior to stroke was not associated with a higher risk of intracranial hemorrhage, major bleeding, or mortality in patients receiving intravenous alteplase for acute ischemic stroke.
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Affiliation(s)
- Tou-Yuan Tsai
- Emergency Department, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Chang Liu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wan-Ting Huang
- Epidemiology and Biostatistics Center, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital and School of Dentistry, National Taiwan University, Taipei, Taiwan
| | - Shang-Quan Qiu
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Sameer Noor
- Texas Tech University Health Sciences Center, School of Medicine, Lubbock
| | - Yong-Chen Huang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Eric H. Chou
- Department of Emergency Medicine, Baylor Scott & White All Saints Medical Center–Fort Worth, Fort Worth, Texas
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huei-Kai Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- Department of Medical Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
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Lin L, Blair C, Fu J, Cordato D, Cappelen-Smith C, Cheung A, Manning NW, Wenderoth J, Chen C, Bivard A, Butcher K, Kleinig TJ, Choi P, Levi CR, Parsons M. Prior anticoagulation and bridging thrombolysis improve outcomes in patients with atrial fibrillation undergoing endovascular thrombectomy for anterior circulation stroke. J Neurointerv Surg 2023; 15:e433-e437. [PMID: 36944493 DOI: 10.1136/jnis-2022-019560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Where stroke occurs with pre-existing atrial fibrillation (AF)studies validating the safety and efficacy of bridging thrombolysis, and the use of endovascular thrombectomy (EVT) in the setting of prior anticoagulation, are limited to single-center reports. METHODS In a retrospective analysis, AF patients undergoing EVT for anterior circulation large vessel occlusion stroke enrolled in a prospectively-maintained, international multicenter database (International Stroke Perfusion Imaging Registry (INSPIRE)) between 2016 and 2019 were studied. Patients were categorized by anticoagulation status: anticoagulated (warfarin/non-vitamin K oral anticoagulants) versus not anticoagulated. Patients not anticoagulated were further divided into intravenous thrombolysis versus no thrombolysis. Outcomes compared between groups included 90-day modified Rankin Scale, 90-day mortality, rates of symptomatic intracerebral hemorrhage (sICH), and good reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3). RESULTS Of 563 AF patients, 118 (21%) were on anticoagulation. AF patients on anticoagulation showed improved 90-day functional outcomes (adjusted odds ratio (aOR) 1.68, 95% confidence interval (95% CI) 1.00 to 2.82). Mortality (26.3% vs 23.8%), sICH (4.5% vs 3.9%), and rates of good reperfusion (91.3% vs 88.0%) were similar between those anticoagulated and those not anticoagulated. Thrombolysis before EVT in AF patients was independently associated with improved 90-day functional outcomes (aOR 1.81, 95% CI 1.18 to 2.79) and reduced mortality (aOR 0.51, 95% CI 0.31 to 0.84), with similar sICH rates (3.4% vs 4.5%). CONCLUSIONS Anticoagulated patients with AF who underwent EVT had improved 90-day functional outcomes and similar sICH rates. Thrombolysis before EVT in AF patients was associated with improved 90-day functional outcomes and reduced mortality.
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Affiliation(s)
- Longting Lin
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Christopher Blair
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - James Fu
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dennis Cordato
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Andrew Cheung
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Nathan W Manning
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Jason Wenderoth
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
- Advanced Endovascular Therapy, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Chushuang Chen
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Andrew Bivard
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Kenneth Butcher
- Institute of Neurological Sciences, Randwick Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Philip Choi
- Department of Neurology, Eastern Health Box Hill, Melbourne, Victoria, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Mark Parsons
- South-Western Sydney Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia
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Ghannam M, AlMajali M, Galecio‐Castillo M, Al Qudah A, Khasiyev F, Dibas M, Ghazaleh D, Vivanco‐Suarez J, Morán‐Mariños C, Farooqui M, Rodriguez‐Calienes A, Koul P, Roeder H, Shim H, Samaniego E, Leira EC, Adams HP, Ortega‐Gutierrez S. Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e031669. [PMID: 38108256 PMCID: PMC10863770 DOI: 10.1161/jaha.123.031669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use. METHODS AND RESULTS A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration. CONCLUSIONS Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.
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Affiliation(s)
- Malik Ghannam
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Mohammad AlMajali
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | | | - Abdullah Al Qudah
- Department of NeurologyUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Farid Khasiyev
- Department of NeurologySaint Louis UniversitySaint LouisMO
| | - Mahmoud Dibas
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Dana Ghazaleh
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | | | - Cristian Morán‐Mariños
- Unidad de investigación en Bibliometria, Vicerrectorado de InvestigaciónUniversidad San Ignacio de LoyolaLimaPerú
| | - Mudassir Farooqui
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Aaron Rodriguez‐Calienes
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Neuroscience, Clinical Effectiveness and Public Health Research GroupUniversidad Científica del SurLimaPeru
| | - Prateeka Koul
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Hannah Roeder
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - HyungSub Shim
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Edgar Samaniego
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Department of NeurosurgeryUniversity of Iowa College of MedicineIowa CityIA
- Department of RadiologyUniversity of Iowa College of MedicineIowa CityIA
| | - Enrique C. Leira
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Department of NeurosurgeryUniversity of Iowa College of MedicineIowa CityIA
- Department of EpidemiologyUniversity of Iowa College of Public HealthIowa CityIA
| | - Harold P. Adams
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
| | - Santiago Ortega‐Gutierrez
- Department of NeurologyUniversity of Iowa College of MedicineIowa CityIA
- Department of NeurosurgeryUniversity of Iowa College of MedicineIowa CityIA
- Department of RadiologyUniversity of Iowa College of MedicineIowa CityIA
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Behnoush AH, Khalaji A, Bahiraie P, Gupta R. Meta-analysis of outcomes following intravenous thrombolysis in patients with ischemic stroke on direct oral anticoagulants. BMC Neurol 2023; 23:440. [PMID: 38102548 PMCID: PMC10722877 DOI: 10.1186/s12883-023-03498-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND There has been debate on the use of intravenous thrombolysis (IVT) in patients with ischemic stroke and the recent use of direct oral anticoagulants (DOACs). Studies have compared these patients with non-DOAC groups in terms of outcomes. Herein, we aimed to systematically investigate the association between DOAC use and IVT's efficacy and safety outcomes. RESULTS A comprehensive systematic search was performed in PubMed, Embase, Scopus, and the Web of Science for the identification of relevant studies. After screening and data extraction, a random-effect meta-analysis was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) for comparison of outcomes between patients on DOAC and controls. Six studies were included in the final review. They investigated a total of 254,742 patients, among which 3,499 had recent use of DOACs. The most commonly used DOACs were rivaroxaban and apixaban. The patients on DOAC had significantly higher rates of atrial fibrillation, hypertension, diabetes, and smoking. Good functional outcome defined by modified Rankin Scale (mRS) 0-2 was significantly lower in patients who received DOACs (OR 0.71, 95% CI 0.62 to 0.81, P < 0.01). However, in the subgroup analysis of 90-day mRS 0-2, there was no significant difference between groups (OR 0.71, 95% 0.46 to 1.11, P = 0.14). All-cause mortality was not different between the groups (OR 1.02, 95% CI 0.68 to 1.52, P = 0.93). Similarly, there was no significant difference in either of the in-hospital and 90-day mortality subgroups. Regarding symptomatic intracranial hemorrhage (sICH), the previous DOAC use was not associated with an increased risk of bleeding (OR 0.98, 95% CI 0.69 to 1.39, P = 0.92). A similar finding was observed for the meta-analysis of any ICH (OR 1.15, 95% CI 0.94 to 1.40, P = 0.18). CONCLUSIONS Based on our findings, IVT could be considered as a treatment option in ischemic stroke patients with recent use of DOACs since it was not associated with an increased risk of sICH, as suggested by earlier studies. Further larger studies are needed to confirm these findings and establish the safety of IVT in patients on DOAC.
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Affiliation(s)
- Amir Hossein Behnoush
- School of Medicine, Tehran University of Medical Sciences, Poursina St., Keshavarz Blvd, Tehran, 1417613151, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- School of Medicine, Tehran University of Medical Sciences, Poursina St., Keshavarz Blvd, Tehran, 1417613151, Iran.
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Pegah Bahiraie
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
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9
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Liang H, Wang X, Quan X, Qin B, Zhang J, Liang S, Liang Z. Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis. J Neurol 2023; 270:4192-4200. [PMID: 37314507 DOI: 10.1007/s00415-023-11815-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke. METHODS Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0-1), functional independence (mRS 0-2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model. RESULTS Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67-1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64-1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06-1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10-1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment. CONCLUSION The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.
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Affiliation(s)
- Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xue Wang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Xuemei Quan
- Department of Neurology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, China
| | - Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China.
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