Support for Thrombolytic Therapy for Acute Stroke Patients on Direct Oral Anticoagulants: Mortality and Bleeding Complications.

Background: Alteplase (tPA) is the initial treatment for acute ischemic stroke. Current tPA guidelines exclude patients who took direct oral anticoagulants (DOAC) within the prior 48 hours. In this propensity-matched retrospective study we compared acute ischemic stroke patients treated with tPA who had received DOACs within 48 hours of thrombolysis to those not previously treated with DOACs, regarding three outcomes: mortality; intracranial hemorrhage (ICH); and need for acute blood transfusions (as a marker of significant blood loss). Methods: Using the United States cohort of 54 healthcare organizations in the TriNetx database, we identified 8,582 stroke patients treated with tPA on DOACs within 48 hours of thrombolysis and 46,703 stroke patients treated with tPA not on DOACs since January 1, 2012. We performed propensity score matching on demographic information and seven prior clinical diagnostic groups, resulting in a total of 17,164 acute stroke patients evenly matched between groups. We recorded mortality rates, frequency of ICH, and need for blood transfusions for each group over the ensuing 7- and 30-day periods. Results: Patients treated with tPA on DOACs had reduced mortality (3.3% vs 7.3%; risk ratio [RR] 0.456; P < 0.001), fewer ICHs (6.8% vs 10.1%; RR 0.678; P < 0.001), and less risk of major bleeding as measured by frequency of blood transfusions (0.5% vs 1.5%; RR 0.317; p < 0.001) at 7 days post thrombolytic, than the tPA patients not on DOACS. Findings for 30 days post-thrombolytics were similar/statistically significant with lower mortality rate (7.2% vs 13.1%; RR 0.550; P < 0.001), fewer ICHs (7.6% vs 10.8%; RR 0.705; P < 0.001), and fewer blood transfusions (0.9% vs 2.0%; RR 0.448; P < 0.001). Conclusion: Acute ischemic stroke patients treated with tPA who received DOACs within 48 hours of thrombolysis had lower mortality rates, reduced incidence of ICH, and less blood loss than those not on DOACs. Our study suggests that prior use of DOACs should not be a contraindication to thrombolysis for ischemic stroke.

D-dimer as a Rule-Out for Aortic Dissection.

Introduction Acute aortic dissection (AAD) represents a significant diagnostic challenge with a high mortality rate if not treated promptly. This challenge arises from the diverse clinical presentations of AAD, and its symptom overlap with other medical conditions. Although both helical CT and transesophageal echocardiography are reliable diagnostic tools for AAD, they are not feasible for every suspected case. Furthermore, limited research on D-dimer's utility in ruling out AAD has been conducted due to the condition's rarity. Methods This study utilizes the TriNetX database (https://trinetx.com/), encompassing data from 54 healthcare organizations across the United States over the past two decades from 85 million patients. The objective is to evaluate the sensitivity of an elevated D-dimer level in diagnosing AAD across a much larger patient cohort than previously studied. Results Retrospectively analyzing this dataset, there were 1,319 patients identified with a confirmed AAD who had undergone D-dimer testing within a day of diagnosis. Of these, 1,252 patients exhibited D-dimer levels exceeding 400 ng/ml while 1,227 had levels surpassing 500 ng/ml. Notably, a D-dimer cutoff of 400 ng/ml demonstrated a sensitivity of 0.949 while a 500 ng/ml cutoff yielded a sensitivity of 0.930. Conclusion This large retrospective cohort study demonstrates that a blood D-dimer level is highly sensitive in assaying for AAD. The D-dimer levels analyzed showed a remarkable sensitivity in ruling out AAD, avoiding the need for more invasive testing in low-risk patients.