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New study pinpoints timeline for safe administration of IV tPA for prior stroke patients

Tuesday, January 7, 2020
By William Alexander
Shreyansh Shah

New research indicates intravenous tissue-type plasminogen activator (IV tPA) only increases the risk for brain hemorrhage in patients with previous stroke if the prior occurred within the past two weeks. This retrospective observational study, by Shreyansh Shah, MD, (photo), Ying Xian, MD, PhD, and colleagues, appears in Circulation Cardiovascular Quality and Outcomes.

“This research provides real-world evidence based on actual clinical practice about when it may be safer to offer IV tPA for patients with previous stroke,” said Shah. “We can now say that patients who have had a stroke within the past two weeks are at a higher risk for intracerebral hemorrhage, but if it’s been more than two weeks, clinicians can consider IV tPA after weighing the risks and benefits.”

Clinicians often cite a recent history of an ischemic stroke as a contraindication for IV tPA for acute stroke patients. IV tPA is sometimes used as an off-label treatment in patients with prior stroke, but studies about the safety of IV tPA treatment in these patients have been small and inconsistent.

Using data from the American Heart Association/American Stroke Association’s Get With the Guidelines-Stroke registry, Shah and colleagues identified 293 stroke patients treated with IV tPA who had an ischemic stroke in the previous three months, as well as 30,655 patients with no prior history of stroke. All patients were age 65 or older, linked to Medicare claims and were treated with IV tPA within 4.5 hours of symptom onset.

After stratifying previous stroke patients by the time since their last stroke, they found an elevated risk for symptomatic intracranial hemorrhage (sICH) for patients who had had a stroke in the past 14 days (16.3% vs 4.8%; aOR 3.7; 95% CI 1.62-8.43), but not for other time periods (2.1% vs 4.8%; aOR 0.38; 95% CI 0.05-2.79 for 15 30 days and 78.4% vs 4.8% aOR 1.36; 95% CI 0.77-2.40 for 31-90 days).

Y XianPatients who had previously had a stroke were also more likely to either die in the hospital or be discharged to hospice (25.9% vs. 17.0%; aOR 1.70; 95% CI 1.21-2.38), less likely to be discharged to home (28.3% vs. 32.3%; aOR 0.72; 95% CI 0.54-0.98) or to have good functional outcomes at discharge (modified Rankin Scale 0-1;11.3% vs.20.0%; aOR 0.46; 95% CI 0.24-0.89).

Other authors of the study include Li Lang, PhD, Andrzej Kosinski, PhD, Adrian Hernandez, MD, MS, Lee Schwamm, MD, Eric Smith, MD, MPH, Gregg Fonarow, MD, Deepak Bhatt, MD, MPH, Wuwei “Wayne” Feng, MD, MS, Eric Peterson, MD, MPH. This study was funded by an award from the American Heart Association/American Stroke Association (AHA/ASA 14SDG20460081) to the senior author of the study, Ying Xian, MD, PhD (photo, right).