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Meta-Analysis
. 2023 Dec 19;12(24):e031669.
doi: 10.1161/JAHA.123.031669. Epub 2023 Dec 18.

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis

Malik Ghannam  1 , Mohammad AlMajali  1 , Milagros Galecio-Castillo  1 , Abdullah Al Qudah  2 , Farid Khasiyev  3 , Mahmoud Dibas  1 , Dana Ghazaleh  1 , Juan Vivanco-Suarez  1 , Cristian Morán-Mariños  4 , Mudassir Farooqui  1 , Aaron Rodriguez-Calienes  1   5 , Prateeka Koul  1 , Hannah Roeder  1 , HyungSub Shim  1 , Edgar Samaniego  1   6   7 , Enrique C Leira  1   6   8 , Harold P Adams Jr  1 , Santiago Ortega-Gutierrez  1   6   7
Affiliations
Meta-Analysis

Intravenous Thrombolysis for Acute Ischemic Stroke in Patients With Recent Direct Oral Anticoagulant Use: A Systematic Review and Meta-Analysis

Malik Ghannam et al. J Am Heart Assoc. .

Abstract

Background: Intravenous thrombolysis (IVT) is an effective stroke therapy that remains underused. Currently, the use of IVT in patients with recent direct oral anticoagulant (DOAC) intake is not recommended. In this study we aim to investigate the safety and efficacy of IVT in patients with acute ischemic stroke and recent DOAC use.

Methods and results: A systematic review and meta-analysis of proportions evaluating IVT with recent DOAC use was conducted. Outcomes included symptomatic intracranial hemorrhage, any intracranial hemorrhage, serious systemic bleeding, and 90-day functional independence (modified Rankin scale score 0-2). Additionally, rates were compared between patients receiving IVT using DOAC and non-DOAC by a random effect meta-analysis to calculate pooled odds ratios (OR) for each outcome. Finally, sensitivity analysis for idarucizumab, National Institutes of Health Stroke Scale, and timing of DOAC administration was completed. Fourteen studies with 247 079 patients were included (3610 in DOAC and 243 469 in non-DOAC). The rates of IVT complications in the DOAC group were 3% (95% CI, 3-4) symptomatic intracranial hemorrhage, 12% (95% CI, 7-19) any ICH, and 0.7% (95%CI, 0-1) serious systemic bleeding, and 90-day functional independence was achieved in 57% (95% CI, 43-70). The rates of symptomatic intracranial hemorrhage (3.4 versus 3.5%; OR, 0.95 [95% CI, 0.67-1.36]), any intracranial hemorrhage (17.7 versus 17.3%; OR, 1.23 [95% CI, 0.61-2.48]), serious systemic bleeding (0.7 versus 0.6%; OR, 1.27 [95% CI, 0.79-2.02]), and 90-day modified Rankin scale score 0-2 (46.4 versus 56.8%; OR, 1.21 [95% CI, 0.400-3.67]) did not differ between DOAC and non-DOAC groups. There was no difference in symptomatic intracranial hemorrhage rate based on idarucizumab administration.

Conclusions: Patients with acute ischemic stroke treated with IVT in recent DOAC versus non-DOAC use have similar rates of hemorrhagic complications and functional independence. Further prospective randomized trials are warranted.

Keywords: acute ischemic stroke; coagulopathy; direct oral anticoagulants; idarucizumab; intravenous thrombolysis; safety; symptomatic intracranial hemorrhage.

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Figures

Figure 1
Figure 1. Forest plot for IVT in patients were taking DOAC for symptomatic intracranial hemorrhage.
A, Refers to the meta‐analysis of proportions. B, Refers to the comparative analysis. *: direct communication with the authors. DOAC indicates direct oral anticoagulant; GLMM, generalized linear mixed model; IVT, intravenous thrombolysis; and MH, Mantel–Haenszel.
Figure 2
Figure 2. Forest plot for IVT in patients were taking DOAC for any ICH.
A, Refers to the meta‐analysis of proportions. B, Refers to the comparative analysis. DOAC indicates direct oral anticoagulant; GLMM, generalized linear mixed model; ICH, intracranial hemorrhage; IVT, intravenous thrombolysis; and MH, Mantel–Haenszel.
Figure 3
Figure 3. Forest plot for IVT in patients were taking DOAC for serious systemic bleeding.
A, Refers to the meta‐analysis of proportions. B, Refers to the comparative analysis. DOAC indicates direct oral anticoagulant; GLMM, generalized linear mixed model; IVT, intravenous thrombolysis; and MH, Mantel–Haenszel.
See this image and copyright information in PMC

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