ESOC 2022 | Intravenous thrombolysis in patients with ischemic stroke and DOAC intake
Thomas Meinel, MD, Bern University Hospital, and University of Bern, Bern, Switzerland, discusses the controversies surrounding the use of intravenous thrombolysis in patients with ischemic stroke and recent direct oral anticoagulant (DOAC) intake. Currently, 1 in 6 stroke patients has a history of oral anticoagulation, with this percentage likely to increase as novel indications for DOACs are uncovered. Guidelines from the European Stroke Organisation and the American Heart Association strongly recommend against thrombolysis within 48 hours after last DOAC intake. With many of these patients presenting in the early time window and otherwise qualifying for thrombolysis, this topic remains a significant clinical question. Dr Meinel highlights a retrospective cohort study including 830 patients with ischemic stroke on DOAC therapy who received intravenous thrombolysis and over 19000 patients without prior DOAC therapy. No evidence of harm was seen in the DOAC arm, with patients half as likely to develop symptomatic intercranial hemorrhage and higher odds of independent outcome at 3 months, compared to controls. Selecting patients based on DOAC level-measurements or prior reversal-treatment also seemed to result in safe thrombolysis. This interview took place at the ESOC 2022 congress in Lyon, France.
Transcript (edited for clarity)
Well, obviously my main interest was on our project presented in the late breaking session on the final day on Friday, which is thrombolysis in patients that were on direct oral anticoagulation. Because in my clinical perspective, this is a very relevant problem. We know that one in six patients has previous oral anticoagulation, and most of them DOACs, and the percentage even increases because there is novel indications such as pulmonary embolism, but also the COMPASS regimen and others...
Well, obviously my main interest was on our project presented in the late breaking session on the final day on Friday, which is thrombolysis in patients that were on direct oral anticoagulation. Because in my clinical perspective, this is a very relevant problem. We know that one in six patients has previous oral anticoagulation, and most of them DOACs, and the percentage even increases because there is novel indications such as pulmonary embolism, but also the COMPASS regimen and others. So this percentage is going to go up. And in those patients who qualify for thrombolysis, so they have a severe deficit or an NIHSS of four or higher and present in the early time window, the percentage is even higher. So this raises the question whether we can offer thrombolysis to those.
As you know, DOAC therapy currently is a absolute contraindication in the ESO guideline, but also in the AHA guideline, if a recent intake was within 48 hours. And there are some exceptions such as offering reversal with Praxbind in the patients taking dabigatran or measuring DOAC plasma levels, and then offering thrombolysis if they are low. However, we know from our stroke community that many of the small centers they have DOAC levels not available at nighttime. And also in Switzerland and other countries dabigatran is not widely used, so we cannot reverse them.
And you know that previously VKA was a contraindication, now 1.7 or lower you can thrombolyse them. You know that dual anti-platelets was a contraindication and all those contraindications have been overcome by using observational data. And I think this project with over 800 patients receiving thrombolysis shows that if we use selection approaches such as DOAC plasma level or reversal, but even in patients that did neither of those, we can safely thrombolyse. And this raises the question whether we can remove previous recent intake of DOACs as an absolute contraindication in those patients.
It’s ongoing, we’re currently finalizing the manuscript. And obviously there needs to be more data on this. So we are setting up a prospective registry to follow up on patients receiving thrombolysis despite DOAC therapy.
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