Coagulation Testing in Acute Ischemic Stroke Patients Taking Non–Vitamin K Antagonist Oral Anticoagulants

Purrucker, Jan; Haas, Kirsten; Rizos, Timolaos; Khan, Shujah; Poli, Sven; Kraft, Peter; Kleinschnitz, Christoph; Dziewas, Rainer; Binder, Andreas; Palm, Frederick; Jander, Sebastian; Soda, Hassan; Heuschmann, Peter U.; Veltkamp, Roland

doi:10.1161/strokeaha.116.014963

Cited by 38 publications

(37 citation statements)

References 21 publications

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“…The aim of the current study was not to show whether IVT or EVT in patients on NOAC is safe and effective but using drugspecific plasma levels for patients’ selection is feasible. This approach offers the advantage to base the selection on drug specific plasma levels rather than on non-specific coagulation tests prone to underestimate the anticoagulant effect of NOAC [ 12 ].…”

Section: Discussionmentioning

confidence: 99%

“…Currently, no point-of-care (POC) device exists to reliably measure RivLev. Although, POC to measure INR has been used in patients on NOAC [ 36 ] and approaches using the INR to guide the decision for IVT in patients on rivaroxaban have been proposed [ 34 ], the correlation between INR and RivLev in patients with acute ischemic stroke is currently unclear and risk of false-negative results has been reported [ 12 ].…”

Section: Discussionmentioning

confidence: 99%

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Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice

et al. 2017

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Background and Purpose Standard operating procedures (SOP) incorporating plasma levels of rivaroxaban might be helpful in selecting patients with acute ischemic stroke taking rivaroxaban suitable for IVthrombolysis (IVT) or endovascular treatment (EVT).MethodsThis was a single-center explorative analysis using data from the Novel-Oral-Anticoagulants-in-Stroke-Patients-registry (clinicaltrials.gov:NCT02353585) including acute stroke patients taking rivaroxaban (September 2012 to November 2016). The SOP included recommendation, consideration, and avoidance of IVT if rivaroxaban plasma levels were <20 ng/mL, 20‒100 ng/mL, and >100 ng/mL, respectively, measured with a calibrated anti-factor Xa assay. Patients with intracranial artery occlusion were recommended IVT+EVT or EVT alone if plasma levels were ≤100 ng/mL or >100 ng/mL, respectively. We evaluated the frequency of IVT/EVT, door-to-needle-time (DNT), and symptomatic intracranial or major extracranial hemorrhage.Results Among 114 acute stroke patients taking rivaroxaban, 68 were otherwise eligible for IVT/EVT of whom 63 had plasma levels measured (median age 81 years, median baseline National Institutes of Health Stroke Scale 6). Median rivaroxaban plasma level was 96 ng/mL (inter quartile range [IQR] 18‒259 ng/mL) and time since last intake 11 hours (IQR 4.5‒18.5 hours). Twenty-two patients (35%) received IVT/EVT (IVT n=15, IVT+EVT n=3, EVT n=4) based on SOP. Median DNT was 37 (IQR 30‒60) minutes. None of the 31 patients with plasma levels >100 ng/mL received IVT. Among 14 patients with plasma levels ≤100 ng/mL, the main reason to withhold IVT was minor stroke (n=10). No symptomatic intracranial or major extracranial bleeding occurred after treatment.Conclusions Determination of rivaroxaban plasma levels enabled IVT or EVT in one-third of patients taking rivaroxaban who would otherwise be ineligible for acute treatment. The absence of major bleeding in our pilot series justifies future studies of this approach.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice

et al. 2017

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“… 23 Because NOAC plasma concentrations on admission or measurements of calibrated anti-Xa activity were not available in our stroke cohort, coagulation tests on hospital admission were analysed (as similarly reported in a German registry). 24 Despite uncertain sensitivity and specificity, these tests provide useful information to assess a residual anticoagulant effect of NOACs—in patients with abnormal results—indicating a recent intake. 25 Of note, NOAC patients with elevated routine coagulation tests had a significantly lower probability of severe stroke when compared to patients without antithrombotic medication on admission.…”

Section: Discussionmentioning

confidence: 99%

“…Fourth, we were unable to assess the adherence to NOAC intake and the actual anticoagulatory effect at the time of stroke onset in more detail because specific tests like calibrated anti-Xa activity are not part of clinical routine so far. 24 We addressed this issue by comparing NOAC patients with and without altered routine coagulation tests to those patients without medical stroke prevention. Fifth, due to retrospective data assessment we were unable to assess the impact of pre-hospital time in therapeutic range (TTR) on stroke severity.…”

Section: Discussionmentioning

confidence: 99%

Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation

et al. 2017

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AimsSeveral studies showed reduced stroke severity in patients with atrial fibrillation (AF) if the international normalized ratio (INR) was ≥ 2 at stroke onset. There are no respective data for non-vitamin K-dependent oral anticoagulants (NOACs). The aim of this study was to compare the impact of NOAC or phenprocoumon intake on stroke severity.Methods and resultsIn this single-centre observational study, 3669 patients with acute ischaemic stroke were retrospectively analysed regarding AF status and medication immediately before admission. Using multivariable regression, we analysed the association of pre-admission anticoagulation with severe stroke (National Institutes of Health Stroke Scale score ≥ 11) on admission and poor outcome at discharge (modified Rankin scale score > 2). Before the index stroke, 655 patients had known AF and a CHA2DS2-VASc score ≥ 2. While 325 (49.6%) patients were anticoagulated, 159 (24.3%) were prescribed a NOAC and 75 (11.5%) phenprocoumon patients had an INR ≥ 2 on admission. Compared with AF patients without medical stroke prevention, an INR ≥ 2 [OR 0.23 (95% CI 0.10–0.53)] or NOAC intake [OR 0.48 (95% CI 0.27–0.86)] were associated with a lower probability of severe stroke after adjustment for confounders, while an INR < 2 [OR 0.62 (95% CI 0.33–1.16)] was not. Adjusted odds ratios for poor functional outcome at hospital discharge were 0.47 (95% CI 0.27–0.84) for NOAC patients, 0.33 (95% CI 0.17–0.65) for INR ≥ 2 and 0.61 (95% CI 0.32–1.16) for INR < 2.ConclusionNOAC intake before stroke did reduce the probability of severe stroke on hospital admission and poor functional outcome at hospital discharge as similarly demonstrated for phenprocoumon patients with an INR ≥ 2 on admission.

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“…The incidence of stroke ranges from 1% to 2% in the subset of AF under anticoagulation therapy. Both assessment of adherence to NOAC therapy and measurement of anticoagulant plasma level on admission remains crucial to optimize the secondary prevention strategy [107].…”

Section: Patients Presenting With Acute Stroke: Use Of Endovascular Tmentioning

confidence: 99%

Use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation — Messages from the 2018 EHRA

et al. 2018

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Coagulation Testing in Acute Ischemic Stroke Patients Taking Non–Vitamin K Antagonist Oral Anticoagulants

Cited by 38 publications

References 21 publications

Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice

Intravenous Thrombolysis in Patients with Stroke Taking Rivaroxaban Using Drug Specific Plasma Levels: Experience with a Standard Operation Procedure in Clinical Practice

Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation

Use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation — Messages from the 2018 EHRA

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