Abstract 2287: Treatment of Acute Stroke in Patients on Dabigatran: A Survey of US Stroke Specialists
Background and Purpose: There are no guidelines for the use of thrombolytic therapy in acute stroke patients taking dabigatran (DBT), or DBT reversal strategies in patients with ICH. We assessed how stroke neurologists plan to care for these patients.
Methods: An internet-based questionnaire was sent to all US board-certified stroke neurologists. Case scenarios for patients on DBT with acute ischemic stroke were presented with varying stroke severity, time from symptom onset and last DBT dose, and activated partial thromboplastin time (PTT), and questions assessed whether and when IV and/or catheter-based thrombolysis would be used. Questions also assessed treatment of patients with DBT-associated ICH. Open-ended comments on the cases were also solicited.
Results: Responses were available from 221/809 stroke neurologists surveyed. Of these, 88% reported that they were somewhat or very familiar with DBT. For an ischemic stroke patient 2 hours post onset and eligible for IV tPA except for use of DBT (time of last dose unknown), 49% would not treat with IV tPA regardless of PTT, 28% would treat if the PTT was normal, 9% if PTT <40 sec, and 4% regardless of PTT. Stroke severity did not appear to greatly modify the decision to treat. When time of last DBT dose was known and the PTT was normal, 21% would treat regardless of time since last dose, 14% would treat only if last dose > 12 hours, 15% only if > 24 hrs, 13% if >48 hrs, 5% if > 4 days, and 15% would not treat regardless of the time from last dose; 10% wanted additional information such as creatinine clearance. For the 3-4.5 hour window, 26% indicated they would be equally likely to treat as within 3 hours, 26% would be less likely to treat, 17% would not treat, and 24% would not treat in < 3 or 3-4.5 hours. Between 8-14% of respondents answered the above questions by saying they were not sure what they would do. For catheter-based lysis, 25% indicated they would treat with IV tPA but would prefer catheter lysis if available, 30% indicated they would use IV tPA and consider catheter lysis as they would for any patient not on DBT, 36% would only use catheter lysis, and 9% would not use IV tPA or catheter lysis. For a patient with DBT associated ICH, 73% said they would attempt reversal of DBT. The following reversal strategies were chosen (more than one could be selected): FFP -53%; factor VIIa - 24%; prothrombin complex concentrates - 61%; platelet transfusion - 7%; hemodialysis - 24%. Some respondents commented that they would use thrombin time and not PTT to select patients on DBT for lysis, and many requested guidance on what should be done in these scenarios.
Conclusions: There is a remarkable lack of consensus amongst stroke neurologists regarding the assessment and treatment of acute stroke patients on DBT. More data on the evaluation and treatment of these patients is urgently needed.
- © 2012 by American Heart Association, Inc.