2023-06-22 16:30:33
Thrombolysis is an established means of treating strokes. In patients who take anticoagulants, the risk of cerebral hemorrhage increases. Is the paradigm shift coming now?
Treatment for stroke has made tremendous strides in the last few decades, particularly with the advent of thrombolysis – a procedure that uses a drug to break up the blood clot and restore blood flow to the brain. But more and more patients are taking so-called DOAK. These are blood thinners in the form of direct oral anticoagulants, which have been established for many years and have almost completely replaced the well-known vitamin K antagonists (VKA) such as Marcumar, with a few exceptions.
Serious side effects: also with DOAK?
During therapy with VKA, the risk of bleeding – especially for cerebral hemorrhage – is significantly increased, so that thrombolysis therapy can usually not be carried out in the case of an acute sleep attack, since serious side effects such as cerebral hemorrhage must be expected. Due to this fact, it was assumed for a long time that severe side effects must also be expected under DOAC therapy. Although it is possible in principle to antagonize the effect of some DOACs by means of antibody therapy prior to lysis therapy, this has so far not played a major role in everyday clinical practice.
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This presents the practitioner with a major dilemma: the blood thinning is intended to protect patients from ischemic events such as strokes. But if a stroke occurs during therapy, you are often powerless. A large international, multi-center retrospective cohort study, which started in early 2023 in JAMA Neurology was released could finally change that.
DOAK is superior
A total of 33,207 patients treated with thrombolytic therapy for acute ischemic stroke were examined in 64 centers worldwide for the study. 832 of these patients were previously taking oral anticoagulation with a DOAC. These were further subdivided into subgroups so that the DOAC effect had been antagonized beforehand in about a third of the patients. In one third, the DOAC levels in the blood were determined beforehand and in the last third the thrombolytic therapy was carried out without any further precautions. The patients were observed for the occurrence of symptomatic cerebral hemorrhages within 36 hours after administration of the thrombolytic therapy. These were previously defined as intracerebral hemorrhages that were visualized by CT morphology and resulted in a worsening of stroke symptoms of at least 4 points on the NIHS scale.
Overall, 4.1% (95% CI, 3.9-4.4) of patients in the control group experienced symptomatic cerebral hemorrhage after thrombolytic therapy. Surprisingly, only 2.5% (95% CI, 1.6–3.8) of patients who had recently taken DOACs experienced symptomatic cerebral hemorrhage. In comparison, the adjusted odds ratio (OR) was 0.57 (95% CI, 0.36-0.92). This finding was consistent in all investigated subgroups of DOAC patients. Even in patients who had taken the last DOAC tablet just a few hours before the thrombolytic therapy, there was no increased rate of intracerebral bleeding.
Thrombolytic therapy and DOAC: safe and effective
Of course, the results of the study are subject to some limitations. These result primarily from the cohort design of the study, so that a certain sample bias cannot be ruled out. The researchers also state that the lysis therapy was carried out according to different standards due to the different circumstances in the respective countries. For example, some patients in the DOAC group only received a reduced thrombolytic dose.
However, the results of the study indicate that thrombolytic therapy is safe and effective in patients taking DOACs. This is an important and, above all, new finding that significantly expands the treatment options in the event of an ischemic stroke in this patient group. A randomized study would be desirable to verify the results obtained from this study, so that these findings can soon find their way into everyday clinical practice.
Image source: DAVE NETTO, unsplash
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