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Question clinique
In patients who receive alteplase for acute stroke, is the recent use of non–vitamin K antagonist oral anticoagulants associated with increased intracranial bleeds?
L’Essentiel
This study found that in patients who presented with acute ischemic stroke and received intravenous alteplase, the recent use of NOACs was not associated with an increased risk of symptomatic intracranial hemorrhage. However, this study had some key limitations that limit the generalizability of the findings. 2b
Référence
Plan de l'etude: Cohort (retrospective)
Financement: Industry + foundation
Cadre: Inpatient (any location)
Sommaire
Current guidelines recommend against the use of alteplase in patients who have taken non–vitamin K antagonist oral anticoagulants (NOACs) in the last 48 hours. Using data from a national US stroke registry during a 5-year period, these investigators identified 163,038 patients who had received intravenous alteplase for the treatment of acute ischemic stroke and had either taken no anticoagulants (n = 160,831) or taken NOACs within the prior 7 days (n = 2207). Patients in the NOAC group were older (median age 75 years vs 70 years in the no anticoagulant group), had more comorbidities, and had more severe strokes based on the National Institutes of Health Stroke Scale. Overall, 3% of patients in the entire cohort developed the primary outcome of symptomatic intracranial hemorrhage within 36 hours after receiving alteplase. After adjusting for factors such as patient demographics, stroke severity, and hospital-level variables, no significant difference was detected in the rate of the primary outcome between the 2 groups. Further, there were no differences in safety outcomes, including serious systemic bleeds, alteplase-related complications, or inpatient mortality. With regard to functional outcomes at discharge, patients in the NOAC group were more likely to be able to ambulate independently, be free of disabilities, be functionally independent, and be discharged to home. There were some key limitations in this study. First, for the patients who took NOACs, the precise timing of the last dose was unknown. The anticoagulant effect of NOACs may not be as potent beyond 48 hours of the last dose. Second, there may be a selection bias when deciding to give alteplase to patients who use NOACs. It is unclear from this study which patients would experience the most benefit and the least harm.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Commentaires
alteplase in cva's
adding alteplase to pts on doac's does not increase intracranial bleeds