Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants

Touzé, Emmanuel; Gruel, Yves; Gouin‐Thibault, Isabelle; Maistre, Emmanuel de; Susen, Sophie; Sié, P.; Derex, Laurent

doi:10.1111/ene.13582

Cited by 64 publications

(58 citation statements)

References 69 publications

(56 reference statements)

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“…[5][6][7] While an INR cut-off value of ≤1.7 is widely accepted for thrombolysis in warfarinised patient based on data from observational studies, there is no such data for DOAC treated patients. [5][6][7] While an INR cut-off value of ≤1.7 is widely accepted for thrombolysis in warfarinised patient based on data from observational studies, there is no such data for DOAC treated patients.…”

Section: Discussionmentioning

confidence: 99%

“…Current experience of intravenous thrombolysis in DOAC patients is mostly limited to using antidote on spec or instigating treatment without DOAC specific testing in the majority of patients. [5][6][7] While an INR cut-off value of ≤1.7 is widely accepted for thrombolysis in warfarinised patient based on data from observational studies, there is no such data for DOAC treated patients. Except in Australia, international stroke guidelines do not include any suggested DOAC drug cut-off levels.…”

Section: Discussionmentioning

confidence: 99%

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Ischaemic stroke and transient ischaemic attack on anticoagulants: outcomes in the era of direct oral anticoagulants

Valente

Leung

et al. 2020

Internal Medicine Journal

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Clinical and imaging characteristics of patients receiving direct oral anticoagulants presenting with transient ischaemic attack or stroke are lacking. A retrospective review of all patients who presented to a high-volume primary stroke centre with acute stroke symptoms while prescribed an oral anticoagulant between January 2012 and June 2017. Clinical, radiological characteristics and functional outcomes were examined. Anticoagulated patients diagnosed with stroke or transient ischaemic attack shared similar disease and outcome characteristics irrespective of anticoagulants used. One-third of warfarin patients with sub-therapeutic international normalised ratios were treated with thrombolytics but no direct oral anticoagulants level was performed in any of the patients, with only one treated by intravenous thrombolysis.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Ischaemic stroke and transient ischaemic attack on anticoagulants: outcomes in the era of direct oral anticoagulants

Valente

Leung

et al. 2020

Internal Medicine Journal

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“…It is expected to be improved in similar cases. In a Franch retrospective research, patients with acute ischemic stroke who were treated with dabigatran within 48 hours were recommended for intravenous thrombolysis after idarucizumab's reversal without direct prothrombin activity monitoring [9] .Giannandrea [10] reviewed 55 thrombolytic cases after idarucizumab reversal of dabigatran showed that 81.9% (45 cases) of patients had improved NIHSS score (median 5 points). In a retrospective study of 120 patients with acute ischemic/hemorrhagic stroke in Germany, the e cacy and safety of idarucizumab reversal of dabigatran in intravenous thrombolysis with acute ischemic stroke had been con rmed.However, in patients with hemorrhagic stroke, the application of can prevent the expansion of hematoma and improve the prognosis of patients [11] .…”

Section: Discussionmentioning

confidence: 99%

Intravenous Thrombolysis after Reversal of Dabigatran with Idarucizumab in Acute Ischemic Stroke: A Case Report

Xie¹,

Wang²,

Li³

et al. 2020

Preprint

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Background: As there is a growing concern about the cerebral embolism events secondary to non-valvular atrial fibrillation, direct oral anticoagulant (DOAC) has been more and more widely used as an anticoagulation treatment for prevention of stroke. However, in the face of life-threatening bleeding or emergency surgery/treatment, doac-related antagonists such as idarucizumab need to be urgently used to reverse the DOAC. Using rt-PA intravenous thrombolysis for acute ischemic stroke requires a time window of 4.5 hours. This case reports rt-PA intravenous thrombolysis after reversal of dabigatran anticoagulation with idarucizumab in patients with acute ischemic stroke. Case presentation: We report the case of 62-year-old Chinese female with nonvalvular atrial fibrillation treated with dabigatran 110mg twice daily, and missed a dose on the eve of the stroke. The patient presented with acute ischemic stroke causing the angle of mouth deviated to right side and left limb weakness in the early morning of the next day. Due to the last dosing time of dabigatran was between 24-48 hours, the patients were given rt-PA intravenous thrombolysis after reversal of dabigatran anticoagulation with idarucizumab, while all contraindications had been excluded by laboratory test and CT scan. NIHSS score was reduced from 4 to 1, and the patient was discharged after 2 weeks. Conclusion: Our case report adds to the evidence that idarucizumab administration is safe and effective in the setting of patients with atrial fibrillation treated with dabigatran who develop acute ischemic stroke requiring rt-PA intravenous thrombolysis.

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“…The improved accuracy at lower dabigatran concentration is most likely secondary to calibration methods, as ECA‐T calibration used 3‐4 points (0 [optional], 30, 255, and 468 ng/mL) and ECA‐II had a fivepoint calibration curve (0, 52, 106, 182, and 270 ng/mL). These data, coupled with the protocol changes (Table 1) would suggest that protocol modifications are required to cover the entire testing range, but no change may be necessary if accuracy is more clinically relevant at lower dabigatran concentrations (<50 ng/mL) for cases of emergent interventions 43,44 . In addition, the methodology of Diagnostica Stago for the ECA‐II assay uses reflex testing meaning that, when the concentration is above the higher calibration point, an automatic re‐dilution of the samples is performed by the analyzer (from 1/5 in the initial analysis to 1/15 in the re‐diluted analysis, increasing the potential range of measurement until 750 ng/mL approximatively).…”

Section: The Ecarin Chromogenic Assaymentioning

confidence: 99%

Ecarin based coagulation testing

Gosselin

Douxfils²

2020

American J Hematol

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Ecarin is derived from venom of Echis carinatus, and will activate prothrombin into meizothrombin which will then cleave fibrinogen to result in clot formation. Ecarin based testing has been described for decades, but these assays were typically restricted to reference or speciality coagulation laboratories. This test was initially described for the assessment of direct thrombin inhibitors (eg, bivalirudin lepirudin, or argatroban) and was not affected by heparins or heparinoids. Ecarin based assays were rarely used for anticoagulation monitoring until the emergence of the direct oral thrombin inhibitor dabigatran etexilate in 2010. As this test was mentioned in the prescribing information for dabigatran etexilate, there was increased interest for use by clinical laboratories as the preferred method for assessing the anticoagulant effect of this drug. The purpose of this document is to review the current status of ecarin based assays for assessing dabigatran. This is with the understanding that these methods can also be exploited for determining the anticoagulation effect of parenteral direct thrombin inhibitors, such as argatroban and bivalirudin.

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Intravenous thrombolysis for acute ischaemic stroke in patients on direct oral anticoagulants

Abstract: In this expert opinion paper, it is suggested that IVT can be performed in patients selected according to the time elapsed since the drug was last taken, renal function, type of hospital where the patient is admitted and plasma concentration of DOAC.

Cited by 64 publications

References 69 publications

Ischaemic stroke and transient ischaemic attack on anticoagulants: outcomes in the era of direct oral anticoagulants

Ischaemic stroke and transient ischaemic attack on anticoagulants: outcomes in the era of direct oral anticoagulants

Intravenous Thrombolysis after Reversal of Dabigatran with Idarucizumab in Acute Ischemic Stroke: A Case Report

Ecarin based coagulation testing

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