■最近服用抗凝剂是急性缺血性卒中溶栓的禁忌症。伊达珠单抗逆转了达比加群的抗凝作用,可能允许溶栓。这项全国性的观察性队列研究,系统审查,和荟萃分析评估了急性缺血性卒中患者在达比加群逆转溶栓之前的疗效和安全性。
我们在意大利17个卒中中心招募了达比加群逆转后接受溶栓治疗的人(逆转组),接受达比加群溶栓治疗但未逆转的患者(未逆转组),和年龄,性别,高血压,中风严重程度,和1:7比例的再灌注治疗匹配的对照(对照组)。我们比较了症状性颅内出血组(sICH,主要结果),任何脑出血,良好的功能结果(3个月时mRS0-2),和死亡。系统审查遵循预定义的协议(CRD42017060274),采用比值比(OR)荟萃分析对各组进行比较.
■达比加群逆转组39例患者和300例匹配的对照。逆转与sICH的非显着增加相关(10.3%vs6%,OR=1.32,95%CI=0.39-4.52),死亡(17.9%vs10%,aOR=0.77,95%CI=0.12-4.93)和良好的功能结果(64.1%vs52.8%,OR=1.41,95%CI=0.63-3.19)。未逆转组(n=12)未记录出血事件或死亡。经过系统评价后,汇集了3项研究的数据(n=1879),逆转对sICH没有显著的趋势(OR=1.53,95%CI=0.67-3.50),死亡(OR=1.53,95%CI=0.73-3.24)和良好的功能结局(OR=2.46,95%CI=0.85-7.16)。
■达比加群逆转后接受再灌注策略治疗的患者似乎sICH风险略有增加,但与卒中患者的功能恢复相当。需要进一步的研究来确定治疗成本效益和血浆达比加群浓度逆转的潜在阈值。
Recent anticoagulant intake represents a contraindication for thrombolysis in acute ischemic stroke. Idarucizumab reverses the anticoagulant effect of dabigatran, potentially allowing for thrombolysis. This nation-wide observational cohort study, systematic
review, and meta-analysis evaluated the efficacy and safety of thrombolysis preceded by dabigatran-reversal in people with acute ischemic stroke.
We recruited people undergoing thrombolysis following dabigatran-reversal at 17 stroke centers in Italy (reversal-group), people on dabigatran treated with thrombolysis without reversal (no-reversal group), and age, sex, hypertension, stroke severity, and reperfusion treatment-matched controls in 1:7 ratio (control-group). We compared groups for symptomatic intracranial hemorrhage (sICH, main outcome), any brain hemorrhage, good functional outcome (mRS 0-2 at 3 months), and death. The systematic
review followed a predefined protocol (CRD42017060274), and odds ratio (OR) meta-analysis was implemented to compare groups.
Thirty-nine patients in dabigatran-reversal group and 300 matched controls were included. Reversal was associated with a non-significant increase in sICH (10.3% vs 6%, aOR = 1.32, 95% CI = 0.39-4.52), death (17.9% vs 10%, aOR = 0.77, 95% CI = 0.12-4.93) and good functional outcome (64.1% vs 52.8%, aOR = 1.41, 95% CI = 0.63-3.19). No hemorrhagic events or deaths were registered in no-reversal group (n = 12). Pooling data from 3 studies after systematic
review (n = 1879), reversal carried a non-significant trend for sICH (OR = 1.53, 95% CI = 0.67-3.50), death (OR = 1.53, 95% CI = 0.73-3.24) and good functional outcome (OR = 2.46, 95% CI = 0.85-7.16).
People treated with reperfusion strategies after dabigatran reversal with idarucizumab seem to have a marginal increase in the risk of sICH but comparable functional recovery to matched patients with stroke. Further studies are needed to define treatment cost-effectiveness and potential thresholds in plasma dabigatran concentration for reversal.