Higher efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants—A new relevant hypothesis

 I have no clue, so ask your competent? doctor what changes to the initial stroke protocol this will cause. 

Do you prefer your  doctor and hospital  incompetence NOT KNOWING? OR NOT DOING?

Higher efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants—A new relevant hypothesis

Senta Frol^1,2*Janja Pretnar Oblak^1,2Pawel Kermer^3,4George Ntaios⁵Panagiotis Papanagiotou^6,7Mišo Šabovič^2,8

• ¹Department of Vascular Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
• ²Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
• ³Department of Neurology, Nordwest-Krankenhaus Sanderbusch, Friesland Kliniken GmbH, Sande, Germany
• ⁴University Medical Center Göttingen, Göttingen, Germany
• ⁵Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
• ⁶Clinic of Diagnostic and Interventional Neuroradiology, Klinikum Bremen Mitte, Bremen, Germany
• ⁷Department of Radiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
• ⁸Department of Vascular Disorders, University Medical Center Ljubljana, Ljubljana, Slovenia

Introduction

Direct oral anticoagulants (DOACs) have been established as first-line therapy for stroke prevention in patients with non-valvular atrial fibrillation due to their high safety and efficacy, as demonstrated in large randomized controlled trials (RCTs) (1–4) and real-world data. Despite their efficacy, about 1%−2% of DOAC-treated patients suffer from acute ischemic stroke (AIS) (1–4). At the same time, intravenous thrombolysis (IVT) is recommended as first-line therapy for AIS patients (5, 6). Currently, alteplase is the preferred thrombolytic agent, while tenecteplase, which is more fibrin-specific and has a longer half-life, has recently been approved for IVT in AIS in Europe (7). However, most international guidelines advise against IVT in DOAC-treated patients who have ingested their medication within 48 h prior to AIS onset, except for dabigatran-treated patients reversed by idarucizumab (5, 8).

Ongoing debates regarding IVT safety in patients on DOACs speculate on possible pathophysiological explanations. It was hypothesized that both direct and indirect thrombin inhibition might reduce disruptions to the blood-brain barrier, thereby lowering the risk of hemorrhage (9, 10). Equally important is the high efficacy of IVT in DOAC-treated patients. Recently, no safety concerns regarding IVT were reported while patients receiving IVT were more likely to have good functional outcomes (11, 12).

In this context, this opinion article discusses about the potentially higher efficacy of IVT in patients on DOACs, a topic which warrants more in-depth exploration, such as enhanced fibrinolytic activity.

More at link.