Intravenous Thrombolysis in Acute Ischemic Stroke Patients Pretreated With Non–Vitamin K Antagonist Oral Anticoagulants
An Editorial Review
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- acute ischemic stroke
- intravenous thrombolysis
- non–vitamin K antagonist oral anticoagulants
- onset-to-treatment time
- symptomatic intracranial hemorrhage
Anticoagulation has revolutionized stroke prevention in patients with atrial fibrillation either with vitamin K antagonists (VKA) or non-VKA oral anticoagulants (NOACs). However, a substantial number of patients may experience acute ischemic stroke (AIS) because of inadequate anticoagulation, noncardioembolic stroke pathogenesis, or true treatment failure and can present to the emergency room within the time window for intravenous thrombolysis (IVT).1 In a series of AIS patients potentially eligible for IVT, 8.7% were pretreated with oral anticoagulants.2 Because of the increased bleeding risk in patients pretreated with VKA, IVT is formally contraindicated if international normalized ratio on hospital admission is >1.7 in patients presenting within 3 hours from symptom onset and in all AIS patients regardless of international normalized ratio during the time window of 3 to 4.5 hours,3 whereas IVT is contraindicated if a patient takes oral anticoagulants regardless of international normalized ratio according to the European license of intravenous (IV) tissue-type plasminogen activator (tPA).4 The use of point-of-care international normalized ratio devices has simplified the management of IVT in AIS patients pretreated with VKAs. On the contrary, because NOAC-specific coagulation assays are more complex with limited availability, this specific subgroup of patients is often excluded from IVT.
These treatment recommendations regarding the use of IV-tPA in AIS patients pretreated with NOACs aim to prevent severe bleeding complications, in particular, symptomatic intracranial hemorrhage (sICH). However, because they are based on expert opinion, they could result in withholding IVT in otherwise eligible patients who may eventually benefit from timely tPA administration. Because NOAC use increases exponentially in clinical practice worldwide, there are a growing number of reports of patients on NOACs who receive IVT for …