Current guidelines recommend against the use of intravenous tissue-type plasminogen activator (IV tPA) alteplase in acute ischemic stroke (AIS) patients who are taking non-vitamin K antagonist oral anticoagulants (NOACs). However, there is limited data on the safety and outcomes of IV tPA in these patients.
Using data from the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke) Registry, we examined the outcomes of IV tPA use among AIS patients on NOACs versus those not on anticoagulation from 1752 hospitals between April 2015 and March 2020.
Of the 163,038 AIS patients who were treated with IV tPA within the 4.5-hour treatment window, 2207 (1.4%) were on NOAC therapy. Patients taking NOACs were older, had higher prevalence of cardiovascular comorbidities, and experienced more severe strokes (NIHSS median 10 versus 7; p<0.0001), compared with those not on anticoagulation. Relative to those not, patients on NOACs had an unadjusted risk of symptomatic intracranial hemorrhage (sICH) of 3.7% versus 3.2% and in-hospital mortality of 6.3% versus 4.9%. However, after adjusting for baseline clinical factors, these risks were not statistically different (sICH: aOR, 0.88 [95%CI, 0.70-1.10]; in-hospital mortality: aOR, 0.84 [95%CI, 0.69-1.01]). Rather, patients on NOACs were more likely to ambulate independently (aOR, 1.25 [95%CI, 1.12-1.40]), be discharged home (aOR, 1.17 [95%CI, 1.06-1.29]), and have a modified Rankin Scale of 0-2 (aOR, 1.27 [95%CI, 1.11-1.45]).
Treatment with IV tPA appears to be well tolerated in AIS patients taking NOACs; however, findings should be corroborated among patients whose time of last NOAC dose is known and reported.
Not applicable