Among dabigatran-treated patients with acute ischemic stroke, reversal with idarucizumab before tPA was associated with more favorable outcomes compared to no reversal (OR 5.86; 95% CI 2.45-14.00).
Systematic Review (n=492)
Does intravenous tPA cause prohibitive bleeding risks or improve outcomes in patients with acute ischemic stroke taking NOACs?
Intravenous tPA may be reasonably well tolerated without prohibitive bleeding risks in selected acute ischemic stroke patients on NOACs, and idarucizumab reversal in dabigatran patients is associated with more favorable outcomes.
Odds Ratio: 5.86 (95% CI 2.45–14)
Absolute Event Rate: 79.1% vs 39.2%
Background and Purpose- Although there are no trials or large cohorts to inform clinical care, current guidelines caution against giving intravenous tPA (tissue-type plasminogen activator) to patients with acute ischemic stroke who are taking non-vitamin K antagonist oral anticoagulants (NOACs). We performed a literature review of intravenous tPA in patients treated with NOACs preceding stroke. Methods- A literature search of PubMed was performed encompassing January 2010 to March 2018. Patient characteristics, timing of last medication intake, laboratory testing, use of reversal, and outcomes ≤3 months after discharge were summarized. Results- We identified 55 studies with 492 NOAC patients receiving tPA (dabigatran, 181; rivaroxaban, 215; apixaban, 40; and unspecified NOAC, 56). Among patients with complete data, the median time from the last NOAC intake to symptom onset was 8 hours (interquartile range, 2.5-14.5), with 55.2% (80/145) within 12 hours. Few patients underwent sensitive laboratory tests, such as thrombin time, diluted thrombin time, or anti-Xa assays before tPA administration. The overall observed rates of symptomatic intracranial hemorrhage, mortality, and favorable outcomes (National Institutes of Health Stroke Scale score, ≤1; modified Rankin Scale score, 0-2; or neurological improvement in the National Institutes of Health Stroke Scale score, ≥8 points) were 4.3% (20/462), 11.3% (48/423), and 43.7% (164/375), respectively. Among dabigatran-treated patients, reversal with idarucizumab was associated with fewer symptomatic intracranial hemorrhage (4.5% 2/44 versus 7.4% 8/108; unadjusted odds ratio, 0.60; 95% CI, 0.12-2.92), death (4.5% 2/44 versus 12.0% 13/108; unadjusted odds ratio, 0.35; 95% CI, 0.08-1.61), and more favorable outcomes (79.1% 34/43 versus 39.2% 29/74; unadjusted odds ratio, 5.86; 95% CI, 2.45-14.00), although the differences were not statistically significant for symptomatic intracranial hemorrhage and death. Conclusions- These preliminary observations suggest that tPA may be reasonably well tolerated without prohibitive risks of bleeding complications in selected patients on NOACs. Reversal of anticoagulant effects by idarucizumab for dabigatran-treated patients before tPA is an emerging strategy that was associated with more favorable outcomes.
Jin et al. (Sat,) conducted a systematic review in Acute Ischemic Stroke (n=492). Idarucizumab reversal before intravenous tPA vs. No reversal was evaluated on Favorable outcomes (NIHSS score ≤1, mRS score 0-2, or NIHSS improvement ≥8 points) (OR 5.86, 95% CI 2.45-14.00). Among dabigatran-treated patients with acute ischemic stroke, reversal with idarucizumab before tPA was associated with more favorable outcomes compared to no reversal (OR 5.86; 95% CI 2.45-14.00).