Impact of atrial fibrillation on the treatment effect of bridging thrombolysis in ischemic stroke patients undergoing endovascular thrombectomy: a multicenter international cohort study

Abstract

BackgroundThe role of bridging intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in the treatment of acute ischemic stroke (AIS) remains debatable. Atrial fibrillation (AF) associated strokes may be associated with reduced treatment effect from IVT. This study compares the effect of bridging IVT in AF and non-AF patients.MethodsThis retrospective cohort study comprised anterior circulation large vessel occlusion (LVO) AIS patients receiving EVT alone or bridging IVT plus EVT within 6 hours of symptom onset. Primary outcome was good functional outcome defined as modified Rankin Scale (mRS) 0–2 at 90 days. Secondary outcomes were successful reperfusion defined as expanded Thrombolysis In Cerebral Infarction (eTICI) grading ≥2b flow, symptomatic intracerebral hemorrhage (sICH), and in-hospital mortality.ResultsWe included 705 patients (314 AF and 391 non-AF patients). The mean age was 68.6 years and 53.9% were male. The odds of good functional outcomes with bridging IVT was higher in the non-AF (adjusted odds ratio (aOR) 2.28, 95% CI 1.06 to 4.91, P=0.035) compared with the AF subgroups (aOR 1.89, 95% CI 0.89 to 4.01, P=0.097). However, this did not constitute a significant effect modification by the presence of AF on bridging IVT (interaction aOR 0.12, 95% CI −1.94 to 2.18, P=0.455). The rate of successful reperfusion, sICH, and mortality were similar between bridging IVT and EVT for both AF and non-AF patients.ConclusionThe presence of AF did not modify the treatment effect of bridging IVT. Further individual patient data meta-analysis of randomized trials may shed light on the comparative efficacy of bridging IVT in AF versus non-AF LVO strokes.

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

“…Six records were retained for full-text screening, and two additional studies were identified by expert advice. Ultimately, 8 studies [ 27 – 34 ], involving 6798 patients, met our inclusion criteria and reported relevant outcomes (Fig. 1 ).…”

“…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 .…”

“…Seven studies [ 27 – 32 , 34 ] compared the good clinical outcome of 6267 AIS-LVO patients with AF. Our data showed that IVT plus EVT was associated with good clinical outcomes at 3 months compared with EVT alone (OR, 1.27 [95% CI, 1.05–1.54]; P = 0.01) (Fig.…”

“…Successful reperfusion rates were reported in 7 studies [ 27 – 30 , 32 , 34 ] involving 5,451 AIS-LVO patients with AF. The successful reperfusion rate was not significantly different between IVT plus EVT and direct EVT (OR, 0.98 [95% Cl, 0.83–1.17]; P = 0.84), and no heterogeneity was observed across studies ( I 2 = 0%, P = 0.91) (Fig.…”