The clinical outcomes following mechanical thrombectomy (MT) appears to be better in patients taking direct oral anticoagulants (DOA), compared with vitamin K antagonists (VKA), with a higher rate of successful recanalization, good and excellent neurological function, and lower mortality risk, according to study results published in Neurology.
Although intravenous thrombolysis with recombinant tissue plasminogen activator was found to be effective in acute ischemic stroke (AIS), prior anticoagulant treatment is one of the main contraindications to this treatment. MT may be a safe and effective reperfusion approach for AIS in anticoagulated patients with large vessel occlusion, but there are no previous studies to compare the results of the intervention for patients treated with VKA or DOA before stroke onset.
The primary outcome of this study was the percentage of patients who achieved a favorable 90-day outcome, defined as modified Rankin scale (mRS) score of 0-2 or equal to prestroke mRS. Secondary outcomes included various clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) and procedural (rates of reperfusion at end of procedure, number of passes >2, procedural complications) outcomes according to anticoagulation subgroup.
The study cohort included 221 AIS patients from the Endovascular Treatment in Ischemic Stroke treated with MT, who were effectively treated with VKA (48%, n=106) or DOA (52%, n=115) before stroke onset. Distal aspiration was used for 50% of DOA-treated patients and 49% of VKA-treated patients, whereas stent retriever was used for 25% and 37% of patients, respectively, and combination of both techniques was used for 18% and 14% of patients, respectively.
The primary outcome of favorable 90-day outcome was achieved more frequently in DOA-treated patients, compared with VKA-treated patients (39.1% vs 31.1%, respectively; odds ratio [OR] 1.92; 95% CI, 0.95-3.87, P =.069).
Multivariate analysis revealed lower 90-day all-cause mortality rates in DOA-treated patients (23.5% vs 36.6%, respectively; adjusted OR 0.47; 95% CI, 0.24-0.89, P =.029). The decrease in NIHSS score was greater among DOA-treated patients, compared with VKA-treated patients (4.9 vs 1.9 points, P =.037).
As for procedural outcomes, successful reperfusion was significantly more common in DOA-treated patients, compared with VKA-treated patients (92.0% vs 74.3%; OR 3.27; 95% CI, 1.40-7.65, P =.006), as was near-complete reperfusion (58.9% vs 41.0%; OR 2.00; 95 CI, 1.08-3.73, P =.028). However, there were no differences in complete reperfusion between the groups.
There was no significant between-group difference in hemorrhagic or procedural complications.
The researchers acknowledged several study limitations, including potential unmeasured cofounders, missing data on some covariates and on clot burden, and differences in antiaggregant use between the groups.
“Future European Society of Cardiology Guidelines for the Management of Atrial Fibrillation could consider our results for recommending DOA to prevent stroke in preference to VKA,” the study authors concluded. They add that, “Our study provides new evidence of benefits of DOA use in clinical practice.”
L’Allinec V, Sibon I, Mazighi M, et al. MT in anticoagulated patients: Direct oral anticoagulants versus vitamin K antagonists [published online ahead of print, 2020 Jan 20]. Neurology. doi: 10.1212/WNL.0000000000008873