Assessing mortality and safety of IV thrombolysis in ischemic stroke patients on direct oral anticoagulants (DOACs): A systematic review and meta-analysis

Background

Intravenous thrombolysis (IVT) is considered a standard reperfusion therapy for acute ischemic stroke (AIS) patients presenting within 4.5 hours of the last known well (LKW). Current guidelines contraindicate the use of IVT in patients within the window who are on Direct Oral Anticoagulants (DOACs) and took their last dose within 48 hours of presentation, due to a risk of symptomatic intracranial hemorrhage (sICH).

Objective

To assess the safety of IVT as management of AIS in patients who take DOACs.

Methods

A thorough literature search of four databases (PubMed, Scopus, Medline, Google Scholar, Web of science and ScienceDirect) was done from inception until May 2023. Double-arm studies that reported outcomes of mortality, sICH, and mRS scores were selected. Results from these studies were presented as odds ratios (ORs) with 95 % confidence intervals (CIs) and were pooled using a random-effects model.

Results

Four eligible studies were included with a total of 238,425 stroke patients who underwent IVT (3330 in the DOAC arm and 235,217 in the placebo arm). The group with prior DOAC intake showed a significant decrease in sICH development and an increase in functional independence at 90 days compared to the control group. No significant association was seen between prior DOAC use and any serious alteplase-related complication within 36 hours, serious systemic or life-threatening hemorrhage within 36 hours, mortality within 3 months, or mRS score at 3 months.

Conclusion

The pooled analysis suggests that IVT is a safe management option for acute ischemic stroke in patients with DOAC intake before symptom onset without an increased risk of serious adverse events.