Use of Intravenous Recombinant Tissue Plasminogen Activator in Acute Ischemic Stroke Patients Taking Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) Before Stroke
Background—Intravenous recombinant tissue plasminogen activator (rt-PA) is effective in improving outcomes in ischemic stroke; however, there are few data on 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 ischemic stroke patients receiving anticoagulation with NOACs versus those on warfarin (international normalized ratio <1.7) or not on anticoagulation from 1,289 registry hospitals between October 2012 and March 2015.
Results—Of 42,887 ischemic stroke patients 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 more severe strokes than those not on anticoagulation (median NIHSS 12, 13, and 9, respectively). Unadjusted rates of symptomatic intracranial hemorrhage (sICH) in the NOAC, warfarin, and none groups were 4.8%, 4.9%, and 3.9% respectively (p=0.11). Compared with those not on anticoagulation, the adjusted odds ratio (OR) for sICH for those on NOACs was 0.92 (95% confidence intervals [CI] 0.51-1.65) and for those on warfarin 0.85 (95% CI 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 mRS at discharge across three groups. Similar results were also found after propensity score matching.
Conclusions—While experience of using rt-PA in ischemic stroke patients 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 study should evaluate the safety and efficacy of intravenous rt-PA in ischemic stroke patients taking NOACs.
- Received June 9, 2016.
- Revision received January 3, 2017.
- Accepted January 17, 2017.