Effect of Alteplase Use on Outcomes in Patients With Atrial Fibrillation: Analysis of the Initiation of Anticoagulation After Cardioembolic Stroke Study

Abstract

Background Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90‐day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)‐related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. Methods and Results We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90‐day mortality. There were 1889 patients (90.6%) who had 90‐day follow‐up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57–3.17) but reduced risk of 90‐day mortality (OR, 0.58; 95% CI, 0.39–0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90‐day mortality (OR, 0.68; 95% CI, 0.45–1.04). Conclusions Alteplase reduced 90‐day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.

Safety and efficacy of intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation

“…Among the eight included studies, six [ 27 – 29 , 31 – 33 ] were retrospective observational studies, and two [ 30 , 34 ] were prospective observational studies. The number of patients per study ranged from 94 to 2311.…”

“…The number of patients per study ranged from 94 to 2311. Four studies [ 28 , 29 , 31 , 34 ] were determined to be of good quality, and the other four studies [ 27 , 30 , 32 , 33 ] were of acceptable quality (Supplementary eTable 2 ). Characteristics of eligible studies are summarized in Table 1 .…”

Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes—A Comprehensive Systematic Review and Meta-Analysis

“…However, there remains a need for more primary studies that specifically investigate the interaction between AF and the effects of BT. Some studies have delved into potential differences in clinical outcomes between AF patients treated with BT and those receiving EVT alone [ 28 , 73 , 74 , 81 , 120 , 121 ]. It has been postulated that the additional IVT could be detrimental in AF patients, as it may increase the odds of sICH without enhancing functional outcomes [ 28 ].…”