2024-01-17 07:00:00
The study (JAMA Intern Med. 2023; online November 20) looked at the risk of bleeding and death after thrombolysis treatment for acute cerebral infarction in patients who use DOACs, compared to patients who do not use DOACs.
The Taiwanese researchers conducted a cohort study with a meta-analysis for this purpose. The primary outcome was intracranial hemorrhage after thrombolysis with intravenous alteplase during hospital admission. Secondary outcomes were major bleeding and death during hospital admission. Propensity score matching was used for the analysis to correct for possible confounders.
A total of 7483 patients were included in the study (mean age: 67 years; 38.9% female). Before the stroke, 91 patients (1.2%) used DOACs, 182 patients (2.4%) warfarin and 7210 patients (96.4%) did not use anticoagulant medication.
The patients taking DOACs had no higher risk of intracranial bleeding than the patients not taking anticoagulation (risk difference: 2.47%; 95% CI: -4.23-9.17, OR: 1.37; 95% -CI: 0.62-3.03). Patients taking DOACs also had no higher risk of the secondary outcome measures: major bleeding (risk difference: 4.95%; 95% CI: -2.56-12.45, OR: 1.69; 95% CI: 0.83-3.45) and death (risk difference: -4.95%; 95% CI: -10.11-0.22, OR: 0.45; 95% CI: 0.15-1, 29). There was also no difference between patients taking DOACs or warfarin. The authors therefore conclude that the risk of bleeding and death is not greater in patients taking DOACs.
‘There are a number of things to comment on this study,’ says Raoul Kloppenborg, vascular neurologist at the Haaglanden Medical Center, in response. ‘Firstly, it remains observational data. These do not simply apply in daily practice. In addition, the external validity for Caucasian populations may be less good, as the prevalence of stroke differs between Asian and Caucasian people. Furthermore, the numbers involved are very small and the point estimators in all cases are to the disadvantage of DOAC use, despite the fact that this is not significant. Given the seriousness of this iatrogenic complication, caution remains the advice.’
Guidelines vary in the Netherlands. At the LUMC, thrombolysis is only administered if it has been more than 4 hours since a DOAC was taken and if the clotting times are not abnormal. At the AMC, thrombolysis is only administered if the last DOAC intake was more than 48 hours ago. Kloppenborg: ‘Individual criteria should determine the decision whether or not to give alteplase. Consider it, for example, in the event of a serious failure, where the risk is justifiable. And first consider alternatives: when using dabigatran, you can first perform surgery with idarucizumab. If there is a proximal occlusion, alteplase should be skipped and thrombectomy should be started immediately.’
#Thrombolysis #DOAC #appears #safe