Safety of thrombolysis with IV rt-PA in patients with atrial fibrillation related ischemic strokes and prior subtherapeutic use of coumarinic anticoagulants
Authors:   Department of Neurology, Emergency University Hospital, Bucharest, Romania, Terecoasa Elena , Tiu Cristina ,   Department of Neurology, Emergency University Hospital, Bucharest, Romania, Masjuan Jaime ,   Department of Neurology, University Hospital Ramón y Cajal, IRYCIS, Madrid, Spain, Alonso de Lecinana Maria ,   Department of Neurology, University Hospital Ramón y Cajal, IRYCIS, Madrid, Spain, Dan Gheorghe A ,   Department of Cardiology, Colentina University Hospital, Bucharest, Romania
Published: October 2022

Background and purpose. There are conflicting data in the literature regarding the safety of intravenous thrombolysis in patients with ischemic strokes receiving prior treatment with vitamin K antagonists. We aimed to assess the safety, short term outcome and mortality after rt-PA administration in patients with atrial fibrillation related strokes and prior subtherapeutic use of vitamin K antagonists. Methods. The study included 210 patients with atrial fibrillation who received treatment with intravenous rt-PA for acute ischemic stroke. We compared the frequency of bleeding complications, including intracerebral hemorrhage of any type and symptomatic intracerebral hemorrhage in patients with and without preadmission acenocoumarol use. We also investigated whether there were differences regarding short term functional outcome (assessed with the modified Rankin score at three months after thrombolysis) and mortality rates between them. Results. 48 patients (22.8%) were receiving acenocoumarol before admission and had international normal ratio (INR) ≤ 1.7. In this group, the median INR value was 1.4 (IQR 1.3-1.6). Preadmission coumarinic anticoagulants use was neither associated with secondary intracerebral hemorrhage of any type (p = 0.9), nor with symptomatic intracerebral hemorrhage (p = 0.9). Moreover, no differences regarding short term stroke outcome (p = 0.86), and mortality (p = 0.56) were observed between patients with or without prior acenocoumarol use. Using logistic regression analysis NIHSS score was found to be the only independent predictor for both short term stroke outcome (OR = 0.82; 95% CI 0.77-0.87; p < 0.0001) and mortality (OR = 1.18; 95%CI 1.09-1.27; p < 0.0001). Chronic heart failure was a second independent predictor for mortality (OR = 3.66; 95%CI 1.41-9.5; p = 0.007). Blood pressure values of more than 185/110 mmHg during the first 24 hours after stroke onset were independently associated with the short term stroke outcome (OR 0.37; 95% CI 0.15-1.88; p = 0.02). Conclusion. In the present study the rates of intracranial hemorrhage and mortality following intravenous thrombolysis for atrial fibrillation related ischemic strokes were not different between the patients who were prior receiving subtherapeutic treatment with acenocoumarol and those who were not receiving coumarinic oral anticoagulants at all. As a result, the use of recombinant tissue plasminogen activator in this clinical setting seems to be safe. Further studies with larger number of patients and a prospective design are needed to confirm these findings.