Abstract 12509: Initial Reports on the Safety of Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke Patients Taking Novel Oral Anticoagulants (NOACs)

Abstract

Background: Intravenous tissue plasminogen activator (IV tPA) improves outcomes in ischemic stroke when given early; however, there is limited information on the safety of giving IV tPA to those already on a novel oral anticoagulants (NOACs, dabigatran, rivaroxaban, and apixaban). Given this, the current stroke guidelines warn against use of IV tPA in patients on a NOAC. Methods: We analyzed data from 42,887 ischemic stroke patients treated with IV tPA within 4.5 hours from 1,289 Get With The Guidelines-Stroke hospitals between October 2012 and March 2015. Results: A total of 1751 patients treated with tPA were receiving one of the oral anticoagulants prior to admission (warfarin with INR<1.7 1500, dabigatran 87, rivaroxaban 129, and apixaban 35). Patients taking oral anticoagulants were older (median 79, 74, 71 for warfarin, any NOACs, and no oral anticoagulant, respectively), had more comorbid conditions, and more severe strokes (median NIHSS 13, 12, and 9). Compared with those not on any oral anticoagulant (3.9%), the unadjusted symptomatic intracranial hemorrhage (sICH) rates were higher in warfarin (4.9%) and NOAC (4.8%) patients. These differences were not statistically significant after adjusting for potential confounders in multivariable logistic regression model: adjusted odds ratio 0.85 (95 CI 0.66-1.10) for warfarin and 0.92 (0.51-1.65) for NOACs. Life-threatening or serious systemic hemorrhage, in-hospital mortality, discharge to hospice, and modified Rankin Score at discharge were similar among those on vs not on an oral anticoagulant (Table). Patients receiving NOACs appeared to have higher likelihood of discharge home and being able to ambulate independently at discharge, although the number of NOACs receiving tPA is small and may reflect potential treatment selection. Conclusion: This preliminary experience supports the potential safety of giving IV tPA to selected patients with acute ischemic stroke who were receiving chronic NOACs therapy.