Bleeding risk in patients with cardiac disease from ischaemic stroke reperfusion therapy: an update
Open Access
- 17 August 2021
- journal article
- review article
- Published by BMJ in BMJ Neurology Open
- Vol. 3 (2), e000156
- https://doi.org/10.1136/bmjno-2021-000156
Abstract
Background Intravenous tissue plasminogen activator (rtPA) and arterial endovascular therapy (ET) rapidly restore cerebral perfusion in eligible patients who had an acute ischaemic stroke (AIS). It is unknown whether patients who had an AIS with premorbid cardiac disease respond differently to reperfusion therapies than those without. These patients may have risk factors that worsen outcomes or may represent those who would most benefit from reperfusion therapy. Objective To determine whether patients who had an AIS with the most frequently encountered pre-existing cardiac conditions, atrial fibrillation (AF), heart failure (HF), left ventricular assist devices (LVADs), or taking anticoagulation for cardiac indications, are at increased risk for poor outcome, such as symptomatic intracranial haemorrhage (sICH), after reperfusion therapy. Results Although AF is an independent risk factor for poor poststroke outcomes, intravenous rtPA is not associated with increased risk of sICH for those not on anticoagulants. Likewise, HF is independently associated with mortality post stroke, yet these patients benefit from reperfusion therapies without increased rates of sICH. Patients with LVADs or who are on anticoagulation should not be given IV rtPA; however, ET remains a viable option in those who meet criteria, even patients with LVAD. Conclusion There is no evidence of an increased risk for sICH after intravenous rtPA or ET for those with AF or HF. Intravenous rtPA should not be given to patients on anticoagulation or with LVADs, but ET should be offered to them when eligible. Whenever possible, future AIS reperfusion research should include patients with premorbid cardiac disease as they are frequently excluded, representing a gap in evidence.Keywords
Funding Information
- American Heart Association (19CDA34660295)
- National Institute of Neurological Disorders and Stroke (1K23NS112459)
This publication has 43 references indexed in Scilit:
- Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patientsJournal of NeuroInterventional Surgery, 2014
- Acute Stroke Management in Patients With Known or Suspected Atrial FibrillationCanadian Journal of Cardiology, 2013
- Stroke thrombolysis in patients taking dabigatranInternal Medicine Journal, 2013
- Impact of Atrial Fibrillation on Outcome in Thrombolyzed Patients With StrokeStroke, 2012
- Patient outcomes from symptomatic intracerebral hemorrhage after stroke thrombolysisNeurology, 2011
- Factors influencing hemorrhagic transformation in ischemic stroke: a clinicopathological comparisonEuropean Journal of Neurology, 2006
- Hemorrhagic Transformation Within 36 Hours of a Cerebral InfarctStroke, 1999
- Generalized Efficacy of t-PA for Acute StrokeStroke, 1997
- Stroke Severity in Atrial FibrillationStroke, 1996
- Tissue Plasminogen Activator for Acute Ischemic StrokeThe New England Journal of Medicine, 1995