Ying Xian1, Jerome J Federspiel2, Adrian F Hernandez2, Daniel T Laskowitz2, Lee H Schwamm2, Deepak L Bhatt2, Eric E Smith2, Gregg C Fonarow2, Eric D Peterson2. 1. From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); and Division of Cardiology, University of California, Los Angeles (G.C.F.). ying.xian@duke.edu. 2. From Duke Clinical Research Institute, Durham, NC (Y.X., A.F.H., E.D.P.); Department of Neurology, Duke University Medical Center, Durham, NC (Y.X., D.T.L.); Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD (J.J.F.); Division of Neurology Massachusetts General Hospital, Boston (L.H.S.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.); and Division of Cardiology, University of California, Los Angeles (G.C.F.).
Abstract
BACKGROUND: Intravenous rt-PA (recombinant tissue-type plasminogen activator) is effective in improving outcomes in ischemic stroke; however, there are few data on the use of rt-PA in patients who are receiving a non-vitamin K antagonist oral anticoagulant (NOAC). METHODS: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we examined the outcomes of use of thrombolytic therapy in patients with ischemic stroke who received anticoagulation with NOACs versus those on warfarin (international normalized ratio <1.7) or not on anticoagulation from 1289 registry hospitals between October 2012 and March 2015. RESULTS: Of 42 887 patients with ischemic stroke treated with intravenous rt-PA within 4.5 hours, 251 were taking NOACs (dabigatran 87, rivaroxaban 129, and apixaban 35) before their stroke, 1500 were taking warfarin, and 41 136 were on neither. Patients on NOACs or warfarin were older, had more comorbid conditions, and experienced more severe strokes than did those who were not on anticoagulation (median National Institutes of Health Stroke Scale 12, 13, and 9, respectively). Unadjusted rates of symptomatic intracranial hemorrhage in the NOAC, warfarin, and none groups were 4.8%, 4.9%, and 3.9%, respectively (P=0.11). In comparison with those not on anticoagulation, the adjusted odds ratio for symptomatic intracranial hemorrhage for those on NOACs was 0.92 (95% confidence interval, 0.51-1.65) and for those on warfarin the adjusted odds ratio was 0.85 (95% confidence interval, 0.66-1.10). There were also no significant differences in the risk for life-threatening/serious systemic hemorrhage, any rt-PA complication, in-hospital mortality, and modified Rankin Scale at discharge across 3 groups. Similar results were also found after propensity score matching. CONCLUSIONS: Although experience of using rt-PA in patients with ischemic stroke on a NOAC is limited, these preliminary observations suggest that rt-PA appears to be reasonably well tolerated without prohibitive risks for adverse events among selected NOAC-treated patients. Future studies should evaluate the safety and efficacy of intravenous rt-PA in patients with ischemic stroke who are taking NOACs.
BACKGROUND: Intravenous rt-PA (recombinant tissue-type plasminogen activator) is effective in improving outcomes in ischemic stroke; however, there are few data on the use of rt-PA in patients who are receiving a non-vitamin K antagonist oral anticoagulant (NOAC). METHODS: Using data from the American Heart Association Get With The Guidelines-Stroke Registry, we examined the outcomes of use of thrombolytic therapy in patients with ischemic stroke who received anticoagulation with NOACs versus those on warfarin (international normalized ratio <1.7) or not on anticoagulation from 1289 registry hospitals between October 2012 and March 2015. RESULTS: Of 42 887 patients with ischemic stroke treated with intravenous rt-PA within 4.5 hours, 251 were taking NOACs (dabigatran 87, rivaroxaban 129, and apixaban 35) before their stroke, 1500 were taking warfarin, and 41 136 were on neither. Patients on NOACs or warfarin were older, had more comorbid conditions, and experienced more severe strokes than did those who were not on anticoagulation (median National Institutes of Health Stroke Scale 12, 13, and 9, respectively). Unadjusted rates of symptomatic intracranial hemorrhage in the NOAC, warfarin, and none groups were 4.8%, 4.9%, and 3.9%, respectively (P=0.11). In comparison with those not on anticoagulation, the adjusted odds ratio for symptomatic intracranial hemorrhage for those on NOACs was 0.92 (95% confidence interval, 0.51-1.65) and for those on warfarin the adjusted odds ratio was 0.85 (95% confidence interval, 0.66-1.10). There were also no significant differences in the risk for life-threatening/serious systemic hemorrhage, any rt-PA complication, in-hospital mortality, and modified Rankin Scale at discharge across 3 groups. Similar results were also found after propensity score matching. CONCLUSIONS: Although experience of using rt-PA in patients with ischemic stroke on a NOAC is limited, these preliminary observations suggest that rt-PA appears to be reasonably well tolerated without prohibitive risks for adverse events among selected NOAC-treated patients. Future studies should evaluate the safety and efficacy of intravenous rt-PA in patients with ischemic stroke who are taking NOACs.
Authors: Fatima Ali-Ahmed; Jerome J Federspiel; Li Liang; Haolin Xu; Theresa Sevilis; Adrian F Hernandez; Andrzej S Kosinski; Janet Prvu Bettger; Eric E Smith; Deepak L Bhatt; Lee H Schwamm; Gregg C Fonarow; Eric D Peterson; Ying Xian Journal: Circ Cardiovasc Qual Outcomes Date: 2019-08-15
Authors: Eivind Berge; William Whiteley; Heinrich Audebert; Gian Marco De Marchis; Ana Catarina Fonseca; Chiara Padiglioni; Natalia Pérez de la Ossa; Daniel Strbian; Georgios Tsivgoulis; Guillaume Turc Journal: Eur Stroke J Date: 2021-02-19
Authors: David J Seiffge; Christopher Traenka; Alexandros A Polymeris; Sebastian Thilemann; Benjamin Wagner; Lisa Hert; Mandy D Müller; Henrik Gensicke; Nils Peters; Christian H Nickel; Christoph Stippich; Raoul Sutter; Stephan Marsch; Urs Fisch; Raphael Guzman; Gian Marco De Marchis; Philippe A Lyrer; Leo H Bonati; Dimitrios A Tsakiris; Stefan T Engelter Journal: J Stroke Date: 2017-09-06 Impact factor: 6.967
Authors: Chen Jin; Ryan J Huang; Eric D Peterson; Daniel T Laskowitz; Adrian F Hernandez; Jerome J Federspiel; Lee H Schwamm; Deepak L Bhatt; Eric E Smith; Gregg C Fonarow; Ying Xian Journal: Stroke Date: 2018-09 Impact factor: 7.914