Ahmed Koriesh on Thrombolysis in Stroke Patients on DOACs
Ahmed Koriesh, Director Hospital Neurology Service at Cleveland Clinic Florida, shared on LinkedIn:
”Thrombolysis in Stroke Patients on DOACs — Time to Rethink the Contraindication?
For years, recent DOAC use meant no tPA — a red line in stroke protocols.
Now, a new study challenges this rule.
DO-IT Target Analysis (2025)
28 stroke centers, 1,342 DOAC patients
Objective: Compare outcomes of IVT vs no IVT, and reversal vs no reversal.
Results:
- Symptomatic ICH: 3.0% IVT vs 5.9% no IVT
- Good outcome (mRS 0–2): 62% IVT vs 44% no IVT
- Reversal (idarucizumab) vs no reversal: no difference in bleeding or efficacy
Interpretation: IV thrombolysis in recent DOAC users appears safe, effective, and not dependent on reversal.
DOAC-IVT (2023)
64 centers • >33,000 patients
Objective: Assess bleeding risk with IVT after recent DOAC intake (< 48 h).
Results:
- Symptomatic ICH: 2.5% DOAC vs 4.1% controls (OR 0.57, p = 0.02)
- No increase in bleeding, even without reversal or level check
- sICH similar across strategies: idarucizumab (1.2%) vs no reversal (3.1%)
Interpretation: Carefully selected patients on DOACs may safely receive IVT — even without waiting 48 hours.
Clinical Pearl: We’re shifting from “automatic exclusion” to “measured inclusion.”
Bottom Line: Evidence is growing that DOAC use ≠ absolute contraindication for thrombolysis.
Awaiting further prospective trials (PEARL-DOAC, Prospective DOAC-IVT).
Stroke codes are evolving — from “On DOAC = no tPA” to ”When was the last dose?”’
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