Recanalization therapies in acute ischemic stroke patients: impact of prior treatment with novel oral anticoagulants on bleeding complications and outcome

Circulation. 2015 Sep 29;132(13):1261-9. doi: 10.1161/CIRCULATIONAHA.115.015484. Epub 2015 Jul 31.

Abstract

Background: We explored the safety of intravenous thrombolysis (IVT) or intra-arterial treatment (IAT) in patients with ischemic stroke on non-vitamin K antagonist oral anticoagulants (NOACs, last intake <48 hours) in comparison with patients (1) taking vitamin K antagonists (VKAs) or (2) without previous anticoagulation (no-OAC).

Methods and results: This is a multicenter cohort pilot study. Primary outcome measures were (1) occurrence of intracranial hemorrhage (ICH) in 3 categories: any ICH (ICHany), symptomatic ICH according to the criteria of the European Cooperative Acute Stroke Study II (ECASS-II) (sICHECASS-II) and the National Institute of Neurological Disorders and Stroke (NINDS) thrombolysis trial (sICHNINDS); and (2) death (at 3 months). Cohorts were compared by using propensity score matching. Our NOAC cohort comprised 78 patients treated with IVT/IAT and the comparison groups of 441 VKA patients and 8938 no-OAC patients. The median time from last NOAC intake to IVT/IAT was 13 hours (interquartile range, 8-22 hours). In VKA patients, median pre-IVT/IAT international normalized ratio was 1.3 (interquartile range, 1.1-1.6). ICHany was observed in 18.4% NOAC patients versus 26.8% in VKA patients and 17.4% in no-OAC patients. sICHECASS-II and sICHNINDS occurred in 2.6%/3.9% NOAC patients, in comparison with 6.5%/9.3% of VKA patients and 5.0%/7.2% of no-OAC patients, respectively. At 3 months, 23.0% of NOAC patients in comparison with 26.9% of VKA patients and 13.9% of no-OAC patients had died. Propensity score matching revealed no statistically significant differences.

Conclusions: IVT/IAT in selected patients with ischemic stroke under NOAC treatment has a safety profile similar to both IVT/IAT in patients on subtherapeutic VKA treatment or in those without previous anticoagulation. However, further prospective studies are needed, including the impact of specific coagulation tests.

Keywords: anticoagulants; endovascular procedures; intra-arterial treatment; intracranial hemorrhages; ischemic stroke; non-vitamin K antagonist oral anticoagulants; thrombolytic therapy; vitamin K antagonists.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Disease
  • Administration, Oral
  • Aged
  • Aged, 80 and over
  • Anticoagulants / administration & dosage
  • Anticoagulants / adverse effects
  • Anticoagulants / classification
  • Anticoagulants / therapeutic use*
  • Antithrombins / administration & dosage
  • Antithrombins / adverse effects
  • Antithrombins / therapeutic use*
  • Atrial Fibrillation / complications
  • Brain Ischemia / blood
  • Brain Ischemia / drug therapy*
  • Cerebral Hemorrhage / chemically induced*
  • Cerebral Hemorrhage / epidemiology
  • Cohort Studies
  • Factor Xa Inhibitors / administration & dosage
  • Factor Xa Inhibitors / adverse effects
  • Factor Xa Inhibitors / therapeutic use*
  • Female
  • Fibrinolytic Agents / therapeutic use*
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Pilot Projects
  • Thrombolytic Therapy*
  • Treatment Outcome
  • Vitamin K / antagonists & inhibitors

Substances

  • Anticoagulants
  • Antithrombins
  • Factor Xa Inhibitors
  • Fibrinolytic Agents
  • Vitamin K