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NOAC + Stroke – Thrombolytic or Not?

February 28, 2024

Exciting news! JournalFeed and Dr. Amal Mattu’s Top Picks Video Series is set to GO LIVE this week! It’s free for Gold Spoon members or you can just get the video series. Watch this trailer and get excited!

Written by Millie Cossé

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In this retrospective cohort study, there was no increased risk of intracranial hemorrhage, major bleeding, or in-hospital mortality after thrombolytic therapy in patients taking non-vitamin K antagonist oral anticoagulants compared to those not taking anticoagulants, but read the fine print.

Maybe you can have it all
This cohort study conducted in Taiwan aimed to assess the risk of intracranial hemorrhage after alteplase administration for stroke in patients taking non-vitamin K antagonist oral anticoagulants (NOACs), warfarin, and no anticoagulants. 7,483 patients were included: 91 (1.2%) were taking NOACs, 182 (2.4%) were on warfarin, and 7,210 (96.4%) received no anticoagulants prior to their stroke. The risk of intracranial hemorrhage following alteplase was 9.9% in the NOAC group and 7.4% in the no-anticoagulant group.

In Taiwan, prior to 2019, anticoagulant use was not a contraindication to alteplase administration. However, while not explicitly contraindicated, it is unclear if the patient’s anticoagulation status was considered prior to alteplase administration, which may be a potential source of bias.

How will this change my practice?
Current contraindications to alteplase administration include, “any active anticoagulant use,” and I will continue to practice accordingly. Also, it is important to note that only 91 patients (1.2%) in this study were on NOACs. That said, I’ll be keeping my eye out for a randomized control trial of lytics with and without prior anticoagulant use, and maybe one day it won’t be a consideration for thrombolytic treatment in initial stroke care.

Risk of Bleeding Following Non-Vitamin K Antagonist Oral Anticoagulant Use in Patients With Acute Ischemic Stroke Treated With Alteplase. JAMA Intern Med. 2024 Jan 1;184(1):37-45. doi: 10.1001/jamainternmed.2023.6160.