Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants.

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.; Forlivesi, S.; Kellert, L.; Wischmann, J.; Kristoffersen, E.S.; Beharry, J.; Barber, P.A.; Hong, J.B.; Cereda, C.; Schlemm, E.; Yakushiji, Y.; Poli, S.; Leker, R.; Romoli, M.; Zedde, M.; Curtze, S.; Ikenberg, B.; Uphaus, T.; Giannandrea, D.; Portela, P.C.; Veltkamp, R.; Ranta, A.; Arnold, M.; Fischer, U.; Cha, J.K.; Wu, T.Y.; Purrucker, J.C.; Seiffge, D.J.; Kägi, G.; Engelter, S.; Nolte, C.H.; Kallmünzer, B.; Michel, P.; Kleinig, T.J.; Fink, J.; Rønning, O.M.; Campbell, B.; Nederkoorn, P.J.; Thomalla, G.; Kunieda, T.; Poli, K.; Béjot, Y.; Soo, Y.; Garcia-Esperon, C.; Ntaios, G.; Cordonnier, C.; Marto, J.P.; Bigliardi, G.; Lun, F.; Choi, PMC; Steiner, T.; Ustrell, X.; Werring, D.; Wegener, S.; Pezzini, A.; Du, H.; Martí-Fàbregas, J.; Cánovas-Vergé, D.; Strbian, D.; Padjen, V.; Yaghi, S.; Stretz, C.; Kim, J.T.

doi:10.1001/jamaneurol.2022.4782

Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants.

Details

Download: jamaneurology_meinel_2023_oi_220085_1675444941.60425.pdf (284.88 [Ko])
State: Public
Version: Final published version
License: CC BY 4.0

Serval ID

serval:BIB_D4E5CD2AF412

Type

Article: article from journal or magazin.

Collection

Publications

Institution

UNIL/CHUV

Title

Intravenous Thrombolysis in Patients With Ischemic Stroke and Recent Ingestion of Direct Oral Anticoagulants.

Journal

JAMA neurology

Author(s)

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., Forlivesi S., Kellert L., Wischmann J., Kristoffersen E.S., Beharry J., Barber P.A., Hong J.B., Cereda C., Schlemm E., Yakushiji Y., Poli S., Leker R., Romoli M., Zedde M., Curtze S., Ikenberg B., Uphaus T., Giannandrea D., Portela P.C., Veltkamp R., Ranta A., Arnold M., Fischer U., Cha J.K., Wu T.Y., Purrucker J.C., Seiffge D.J., Kägi G., Engelter S., Nolte C.H., Kallmünzer B., Michel P., Kleinig T.J., Fink J., Rønning O.M., Campbell B., Nederkoorn P.J., Thomalla G., Kunieda T., Poli K., Béjot Y., Soo Y., Garcia-Esperon C., Ntaios G., Cordonnier C., Marto J.P., Bigliardi G., Lun F., Choi PMC, Steiner T., Ustrell X., Werring D., Wegener S., Pezzini A., Du H., Martí-Fàbregas J., Cánovas-Vergé D., Strbian D., Padjen V., Yaghi S., Stretz C., Kim J.T.

Working group(s)

International DOAC-IVT, TRISP, and CRCS-K-NIH Collaboration, DOAC-IVT Writing Group

Contributor(s)

Goeldlin M., Siepen B., Mueller M., Beyeler M., Scutelnic A., Jung S., Mujanovic A., Kurmann C., Dobrocky T., Piechoviak E., Wiest R., Hakim A., Bücke P., Jana Z., Carmen L., Diana Isabella D., Ramos J.N., Strambo D., Buehrer M., Simaan N., Honig A., Filioglo A., Grisendi I., Ferri L., Trapasso M.C., Benini M., Pascarella R., Moratti C., Napoli M., Sumaria S., Gröschel K., Hahn M., Polymeris A., Traenka C., Zietz A., Lyrer P., DeMarchis G.M., Thilemann S., Piot I., Enz L., Peters N., Katan M., Brehm A., Psychogios M., Prange U., Spratt N., Roten L., Chew B.A., Stefela J., von Rennenberg R., Litmeier S., Riegler C., Klammer M., Erdur H., Simon H., Mauro M., Marco L., Francesco C., Sara B., Tan P., Ercegovac M., Berisavac I., Haupenthal D., Gassmann L., Marsch A., Siedler G., Weir L., Pesavento L., Yassi N., Davis S., Ip B., Leung T., Gomez-Exposito A., Mbroh J., Tünnerhoff J., Barbu G., Wang Y., Mengel A., Katharina F., Kowarik M., Ziemann U., Kim J.Y., Kang J., Han M.K., Kim B.J., Choi K.H., Park M.S., Cho K.H., Kim J.T., Shin D.I., Yum K.S., Kim D.H., Cha J.K., Park J.M., Kang K., Kim Y.S., Kim J.G., Lee S.J., Oh M.S., Lee B.C., Lee M., Yu K.H., Park H.K., Hong K.S., Cho Y.J., Choi J.C., Kim J.G., Kang C.H., Sohn S.I., Hong J.H., Jang S.H., Park H., Park T.H., Park S.S., Lee K.B., Kwon J.H., Kim W.J., Lee J., Kwon D.H., Gwak D.S., Kim D.E., Lee K.J., Lee S.H., Kim C., Jeong H.B., Park K.Y., Lee J.S., Lee J., Martinez-Majander N., Sibolt G., Tiainen M., Gentile M., Migliaccio L., Simonetti L., Paolucci M., Flores A., Seró L., Turc G., Oppenheim C., Naggara O., Ben Hassen W., Benzakoun J., Yakushiji Y., Kunieda T.

ISSN

2168-6157 (Electronic)

ISSN-L

2168-6149

Publication state

Published

Issued date

01/03/2023

Peer-reviewed

Oui

Volume

Number

Pages

233-243

Language

english

Notes

Publication types: Journal Article ; Comment
Publication Status: ppublish

Abstract

International guidelines recommend avoiding intravenous thrombolysis (IVT) in patients with ischemic stroke who have a recent intake of a direct oral anticoagulant (DOAC).
To determine the risk of symptomatic intracranial hemorrhage (sICH) associated with use of IVT in patients with recent DOAC ingestion.
This international, multicenter, retrospective cohort study included 64 primary and comprehensive stroke centers across Europe, Asia, Australia, and New Zealand. Consecutive adult patients with ischemic stroke who received IVT (both with and without thrombectomy) were included. Patients whose last known DOAC ingestion was more than 48 hours before stroke onset were excluded. A total of 832 patients with recent DOAC use were compared with 32 375 controls without recent DOAC use. Data were collected from January 2008 to December 2021.
Prior DOAC therapy (confirmed last ingestion within 48 hours prior to IVT) compared with no prior oral anticoagulation.
The main outcome was sICH within 36 hours after IVT, defined as worsening of at least 4 points on the National Institutes of Health Stroke Scale and attributed to radiologically evident intracranial hemorrhage. Outcomes were compared according to different selection strategies (DOAC-level measurements, DOAC reversal treatment, IVT with neither DOAC-level measurement nor idarucizumab). The association of sICH with DOAC plasma levels and very recent ingestions was explored in sensitivity analyses.
Of 33 207 included patients, 14 458 (43.5%) were female, and the median (IQR) age was 73 (62-80) years. The median (IQR) National Institutes of Health Stroke Scale score was 9 (5-16). Of the 832 patients taking DOAC, 252 (30.3%) received DOAC reversal before IVT (all idarucizumab), 225 (27.0%) had DOAC-level measurements, and 355 (42.7%) received IVT without measuring DOAC plasma levels or reversal treatment. The unadjusted rate of sICH was 2.5% (95% CI, 1.6-3.8) in patients taking DOACs compared with 4.1% (95% CI, 3.9-4.4) in control patients using no anticoagulants. Recent DOAC ingestion was associated with lower odds of sICH after IVT compared with no anticoagulation (adjusted odds ratio, 0.57; 95% CI, 0.36-0.92). This finding was consistent among the different selection strategies and in sensitivity analyses of patients with detectable plasma levels or very recent ingestion.
In this study, there was insufficient evidence of excess harm associated with off-label IVT in selected patients after ischemic stroke with recent DOAC ingestion.

Keywords

Neurology (clinical)

URN

urn:nbn:ch:serval-BIB_D4E5CD2AF4126

OAI-PMH

oai:serval.unil.ch:BIB_D4E5CD2AF412

DOI

10.1001/jamaneurol.2022.4782

Pubmed

36807495

Web of science

000909519700002