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Does NOAC Use Preclude tPA for Acute Stroke?

April 7, 2022

Written by Seth Walsh-Blackmore

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There was no significant difference in intracranial hemorrhage, serious systemic hemorrhage, or inpatient mortality for patients who used non-vitamin K oral anticoagulants (NOAC) in the seven days prior to receiving alteplase for acute ischemic stroke.

Why does this matter?
Current AHA/ASA guidelines recommend against alteplase therapy in patients who have taken a NOAC within 48hrs, unless Xa levels and other coagulation factors are normal. NOAC use is increasing, so this will be an increasingly frequent decision point for us.

We could treat this stroke if they weren’t on stroke prophylaxis…
This was a retrospective cohort of patients treated with IV alteplase within 4.5 hours of stroke symptom onset sampled from a validated stroke registry. 160,831 patients with no prior anticoagulant and 2,207 who had taken a NOAC within 7 days of stroke onset were compared for a primary outcome of symptomatic intracranial hemorrhage (ICH) within 36 hours of alteplase administration. The unadjusted rate of ICH was 3.7% (95%CI 2.9% to 4.5%) in patients taking NOACs vs 3.2% (95%CI 3.1% to 3.3%) in patients not taking anticoagulants. After adjustment for NIHSS score and baseline factors, the difference was not significant with aOR 0.88 (95%CI 0.70 to 1.10); adjusted risk difference −0.51% (95%CI −1.36% to 0.34%). Notable secondary outcomes, such as life-threatening or serious systemic hemorrhage and inpatient mortality, were also not significantly different.

This study aims to answer a prescient question in acute stroke management. Although observational, its results are strengthened by a large national sample. Unfortunately, the primary database did not provide an exact timeframe to address the more clinically relevant question: Is alteplase safe within 48 hours of taking a NOAC? This is the cutoff under current guidelines. I would not use these data to support going against current guidelines. The point may become moot, as a recent ACEP clinical policy questions the use of thrombolysis even in patients without AHA/ASA contraindications. However, it is still standard of care at many institutions. If so at yours, consider adding a Xa level to the opening stroke lab panel if uncertain about NOAC use within 48 hours. The processing time for a Xa level is close to an hour, so it’s not a lab you want to be scrambling to add later.

Association of Recent Use of Non-Vitamin K Antagonist Oral Anticoagulants With Intracranial Hemorrhage Among Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA. 2022 Feb 22;327(8):760-771. doi: 10.1001/jama.2022.0948.

Editorial – Intravenous Thrombolytic Therapy for Treatment of Acute Ischemic Stroke in Patients Taking Non-Vitamin K Antagonist Oral Anticoagulants. JAMA. 2022 Feb 22;327(8):725-726. doi: 10.1001/jama.2022.0068.

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