Stroke thrombolysis in patients taking dabigatran

Jayathissa, Sisira; Gommans, John; Harper, Paul

doi:10.1111/imj.12182

Cited by 9 publications

(3 citation statements)

References 13 publications

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“…Among the case reports, ICH and poor outcome were rarely reported when recombinant tissue-type plasminogen activator was administered minutes to 24 hours after the last anticoagulant dose. 74,75 The cohort study 76 comprised 78 NOAC-treated patients undergoing intravenous thrombolysis or intra-arterial therapy a median of 13 hours after the last NOAC dose compared with 441 warfarin-treated patients and 8938 on no anticoagulants. After propensity score matching, there was no significant difference in rate of any ICH, symptomatic ICH, or death among the groups.…”

Section: Management Of Patients On Noacs Who Are At Risk For Bleedingmentioning

confidence: 99%

Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Raval¹,

Cigarroa²,

Chung³

et al. 2017

Circulation

218

147

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Non–vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.

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Section: Management Of Patients On Noacs Who Are At Risk For Bleedingmentioning

confidence: 99%

Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Raval¹,

Cigarroa²,

Chung³

et al. 2017

Circulation

218

147

View full text Add to dashboard Cite

show abstract

“…Human studies are limited to isolated case reports (n=9) of patients taking dabigatran who experienced an AIS and were treated with thrombolysis (47)(48)(49)(50)(51)(52)(53)(54)(55); there are no reports of thrombolysis in stroke patients taking rivaroxaban or apixaban.…”

Section: In Patients Taking a Noac Who Experience An Acute Ischaemic mentioning

confidence: 99%

Unanswered questions and research priorities to optimise stroke prevention in atrial fibrillation with the new oral anticoagulants

Hankey¹

2014

Thromb Haemost

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SummaryThis review article discusses the following, as yet unanswered, questions and research priorities to optimise patient management and stroke prevention in atrial fibrillation with the new direct oral anticoagulants (NOACs): 1. In patients prescribed a NOAC, can the anticoagulant effects or plasma concentrations of the NOACs be measured rapidly and reliably and, if so, can “cut-off points” between which anticoagulation is therapeutic (i.e. the “therapeutic range”) be defined? 2. In patients who are taking a NOAC and bleeding (e.g. intracerebral haemorrhage), can the anticoagulant effects of the direct NOACs be reversed rapidly and, if so, can NOAC-associated bleeding and complications be minimised and patient outcome improved? 3. In patients taking a NOAC who experience an acute ischaemic stroke, to what degree of anticoagulation or plasma concentration of NOAC, if any, can thrombolysis be administered safely and effectively? 4. In patients with a recent cardioembolic ischaemic stroke, what is the optimal time to start (or re-start) anticoagulation with a NOAC (or warfarin)? 5. In anticoagulated patients who experience an intracranial haemorrhage, can anticoagulation with a NOAC be re-started safely and effectively, and if so when? 6. Are the NOACs effective and safe in multimorbid geriatric people (who commonly have atrial fibrillation and are at high risk of stroke but also bleeding)? 7. Can dose-adjusted NOAC therapy augment the established safety and efficacy of fixed-dose unmonitored NOAC therapy? 8. Is there a dose or dosing regimen for each NOAC that is as effective and safe as adjusted-dose warfarin for patients with atrial fibrillation who have mechanical prosthetic heart valves? 9. What is the long-term safety of the NOACs?

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“…Rapid identification of whether a patient is taking a DOAC is imperative, particularly when medication reconciliation is not possible. Patients with normal aPTTs are considered unlikely to be taking dabigatran 26 ; since aPTT remains the most common study ordered in a stroke code, rapid identification of therapeutic dabigatran usage is typically feasible. Dabigatran concentrations or ecarin clotting time can also be used to detect traces of this medication.…”

Section: Resultsmentioning

confidence: 99%

Bleeding risk in patients with cardiac disease from ischaemic stroke reperfusion therapy: an update

Chen

Johansen

2021

BMJ Neurol Open

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BackgroundIntravenous tissue plasminogen activator (rtPA) and arterial endovascular therapy (ET) rapidly restore cerebral perfusion in eligible patients who had an acute ischaemic stroke (AIS). It is unknown whether patients who had an AIS with premorbid cardiac disease respond differently to reperfusion therapies than those without. These patients may have risk factors that worsen outcomes or may represent those who would most benefit from reperfusion therapy.ObjectiveTo determine whether patients who had an AIS with the most frequently encountered pre-existing cardiac conditions, atrial fibrillation (AF), heart failure (HF), left ventricular assist devices (LVADs), or taking anticoagulation for cardiac indications, are at increased risk for poor outcome, such as symptomatic intracranial haemorrhage (sICH), after reperfusion therapy.ResultsAlthough AF is an independent risk factor for poor poststroke outcomes, intravenous rtPA is not associated with increased risk of sICH for those not on anticoagulants. Likewise, HF is independently associated with mortality post stroke, yet these patients benefit from reperfusion therapies without increased rates of sICH. Patients with LVADs or who are on anticoagulation should not be given IV rtPA; however, ET remains a viable option in those who meet criteria, even patients with LVAD.ConclusionThere is no evidence of an increased risk for sICH after intravenous rtPA or ET for those with AF or HF. Intravenous rtPA should not be given to patients on anticoagulation or with LVADs, but ET should be offered to them when eligible. Whenever possible, future AIS reperfusion research should include patients with premorbid cardiac disease as they are frequently excluded, representing a gap in evidence.

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Stroke thrombolysis in patients taking dabigatran

Cited by 9 publications

References 13 publications

Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Management of Patients on Non–Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association

Unanswered questions and research priorities to optimise stroke prevention in atrial fibrillation with the new oral anticoagulants

Bleeding risk in patients with cardiac disease from ischaemic stroke reperfusion therapy: an update

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