For a study, researchers sought to compare the safety and functional results of intravenous alteplase in patients who were using NOACs before stroke with those in patients who were not receiving long-term anticoagulants. A retrospective cohort study of 163,038 patients with acute ischemic stroke treated with intravenous alteplase within 4.5 hours of symptom onset at 1,752 US hospitals participating in the Get With The Guidelines-Stroke program between April 2015 and March 2020, with data from the Addressing Real-world Anticoagulant Management Issues in a Stroke registry. NOACs should be taken 7 days before taking alteplase. The primary endpoint was symptomatic cerebral bleeding within 36 hours of intravenous alteplase treatment. In addition, there were four secondary safety outcomes, including inpatient mortality, and seven secondary functional outcomes, including the proportion of patients released home, that was examined at hospital discharge.
Of 163,038 patients treated with intravenous alteplase (median age, 70 [IQR, 59 to 81] years; 49.1% women), 2,207 (1.4%) were using NOACs prior to their stroke, and 160,831 (98.6%) were not taking anticoagulants. Patients who took NOACs were older (median age, 75 [IQR, 64 to 82] years vs. 70 [IQR, 58 to 81] years for those who did not take anticoagulants), had a higher prevalence of cardiovascular comorbidities, and had more severe strokes (median National Institutes of Health Stroke Scale score, 10 [IQR, 5 to 17] vs. 7 [IQR, 4 to 14]) (all standardized differences >10). The unadjusted risk of an asymptomatic cerebral hemorrhage in individuals using NOACs was 3.7% (95% CI, 2.9% to 4.5%) compared to 3.2% (95% CI, 3.1% to 3.3%) in patients who did not take anticoagulants. After controlling for baseline clinical variables, the risk of symptomatic intracranial hemorrhage did not change substantially across groups (adjusted odds ratio [OR], 0.88 [95% CI, 0.70 to 1.10]; adjusted risk difference [RD], 0.51% [95% CI, 1.36% to 0.34%]). Secondary safety outcomes, such as inpatient mortality (6.3% for patients taking NOACs vs 4.9% for patients not taking anticoagulants; adjusted OR, 0.84 [95% CI, 0.69 to 1.01]; adjusted RD, 1.20% [95% CI, 2.39% to 0%]), revealed no significant differences. Out of 4, around 7 secondary functional outcomes, including the proportion of patients released home, indicated significant differences in favor of the NOAC group after adjustment (45.9% vs. 53.6% for patients not taking anticoagulants; adjusted OR, 1.17 [95% CI, 1.06 to 1.29]; adjusted RD, 3.84% [95% CI, 1.46% to 6.22%]).
Compared to no use of anticoagulants, the use of NOACs during the previous 7 days was not linked with an increased risk of cerebral bleeding in patients with acute ischemic stroke treated with intravenous alteplase.