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Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis

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Abstract

Background

To assess the safety and efficacy of intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS) taking direct oral anticoagulants (DOACs) prior to stroke.

Methods

Literature was searched in PubMed, Cochrane Library, and Embase until March 13, 2023. The primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes included excellent outcome (modified Rankin Scale [mRS] 0–1), functional independence (mRS 0–2), and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were estimated using a random-effects model.

Results

Five non-randomized studies included 239,879 patients with AIS treated with IVT, with 3400 (1.42%) taking DOACs prior to stroke. The rates of sICH did not differ statistically between patients taking DOACs and those not taking anticoagulants (unadjusted OR 0.98; 95% CI 0.67–1.44; P = 0.92; adjusted OR 0.81; 95% CI 0.64–1.03; P = 0.09). Patients taking DOACs had significantly higher adjusted rates of excellent outcome (adjusted OR 1.22; 95% CI 1.06–1.40; P < 0.01) and functional independence (adjusted OR 1.25; 95% CI 1.10–1.42; P < 0.01) at discharge than those not taking anticoagulants. No significant difference was observed in mortality and other efficacy outcomes between groups after adjustment.

Conclusion

The meta-analysis indicated that taking DOACs prior to stroke does not significantly increase the risk of sICH in selected patients with AIS treated with IVT. Furthermore, the benefits of IVT in selected patients taking DOACs appear to be comparable to those not taking anticoagulants. Further research is warranted to confirm the findings.

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Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

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Funding

This study was supported by National Natural Science Foundation of China (82260243), National Key R&D Program of China (no. 2018YFC1311305), and Guangxi Zhuang Autonomous Region Health Commission self-funded project (Z-A20220024).

Author information

Author notes

  1. Huo Liang and Xue Wang contributed equally to this work.

Authors and Affiliations

  1. Department of Neurology, The First Affiliated Hospital of Guangxi Medical University and Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention and Guangxi Clinical Research Center for Cardio-Cerebrovascular Diseases, Nanning, 530021, China

    Huo Liang, Xue Wang, Bin Qin, Jian Zhang, Shuolin Liang & Zhijian Liang

  2. Department of Neurology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, China

    Xuemei Quan

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Contributions

HL and SL reviewed abstracts and titles of potentially relevant studies and screened full-text articles. BQ and XW extracted all the data independently. HL and XQ verified the extracted data. XQ and JZ independently evaluated the quality of the included studies. HL and XW performed all statistical analyses, drafted the manuscript, and made critical revisions. XQ and BQ contributed to the study's design and revised the manuscript. ZL reviewed the manuscript critically. All authors contributed to the article and approved the submitted version.

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Correspondence to Zhijian Liang.

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Ethics approval was not required for this study, given the public nature of the data analyzed.

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Liang, H., Wang, X., Quan, X. et al. Safety and efficacy of intravenous thrombolysis in patients with acute ischemic stroke taking direct oral anticoagulants prior to stroke: a meta-analysis. J Neurol 270, 4192–4200 (2023). https://doi.org/10.1007/s00415-023-11815-x

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