No Evidence of Harm from Prior Anticoagulant Use in Stroke Patients Given Thrombolysis

Research published in JAMA Neurology suggests that recent ingestion of direct oral anticoagulants may not be a contraindication to intravenous thrombolysis in patients with acute ischemic stroke. Current guidelines advise against this practice based on the presumed risk of symptomatic intracranial hemorrhage, but supporting evidence is limited.

In this retrospective analysis, researchers included 33,207 adult patients from 64 health centers in Europe, Australia, Asia, and New Zealand between 2008 and 2021. Participants were included if they had an ischemic stroke that was treated with intravenous thrombolysis and took direct oral anticoagulants within the last 48 hours. The comparison cohort included participants without prior anticoagulant use who had an ischemic stroke treated with intravenous thrombolysis. 

The primary objective was to compare the risk of symptomatic intracranial hemorrhage within 36 hours between cohorts. Participants who received oral anticoagulants and intravenous thrombolysis had lower odds of developing symptomatic intracranial hemorrhage after an ischemic stroke (AOR 0.57; 95% CI, 0.36-0.92). The researchers found that patients who received oral anticoagulants had numerically higher odds of being functionally independent after 90 days (AOR, 01.13; 95% CI, 0.94-1.36; P= 0.20).

According to researchers: “Given the established benefits of intravenous thrombolysis and the absence of any signal for harm in our study or in other clinical studies or pre-clinical investigations, future guideline updates need to re-consider recent direct oral anticoagulant ingestion as a contraindication to intravenous thrombolysis for acute ischemic stroke.”