Efficacy and safety of thrombolysis for acute ischemic stroke with atrial fibrillation: a meta-analysis

Abstract

Background The efficacy and safety of intravenous thrombolysis (IVT) for acute ischemic stroke with atrial fibrillation (AF) is still controversial. Methods We conducted a meta-analysis of all relevant studies, retrieved through systematic search of PubMed, Embase, and Cochrane databases up to December 31, 2019. Modified Rankin Scale (mRS) scores of 0–1 at 90 days, mRS of 0–2 at 90 days, overall mortality, and incidence of symptomatic intracranial hemorrhage (sICH) were collected as outcome measures. Fixed- and random-effects meta-analytical models were applied, and between-study heterogeneity was assessed. Results A total of 8509 patients were enrolled in 18 studies. A comparison of IVT treatment in AF versus non-AF patients showed that AF was associated with a significantly lower proportion of patients with mRS of 0–1 (24.1% vs. 34.5%; OR 0.59; 95% CI 0.43–0.81; P < 0.001), mRS of 0–2 (33.6% vs. 47.8%; OR 0.55; 95% CI 0.43–0.70; P < 0.001), as well as significantly higher mortality (19.4% vs. 11.5%; OR 2.05; 95% CI 1.79–2.36; P < 0.001) and higher incidence of sICH (6.4% vs. 4.1%; OR 1.60; 95% CI 1.27–2.01; P < 0.001). A comparison of AF patients who were subjected or not to IVT showed that thrombolysis carried a higher risk of sICH (5.7% vs. 1.6%; OR 3.44; 95% CI 2.04–5.82; P < 0.001) and was not associated with a better prognosis. Subgroup analysis in prospective studies also suggested a poorer functional prognosis and higher mortality in AF patients treated with IVT compared with those who did not receive IVT. Some heterogeneity was present in this meta-analysis. Conclusions Acute IS patients with AF had worse outcomes than those without AF after thrombolytic therapy, and had a higher incidence of sICH after thrombolysis than those without thrombolysis. Thrombolysis in ischemic stroke patients with AF should be carefully considered based on clinical factors such as NIHSS score, age, and the type of AF.

Stroke Aetiology and Collateral Status in Acute Ischemic Stroke Patients Receiving Reperfusion Therapy—A Meta-Analysis

“…A meta-analysis by Lu et al about the safety and efficacy of IVT for AIS patients with AF and found worse outcomes in AIS patients with AF than those without AF. Authors also reported a higher incidence of sICH in AF patients than in non-AF patients (6.4% vs. 4.1%; p < 0.001), as well as in AF patients receiving IVT compared to AF patients not receiving IVT (5.7% vs. 1.6%; p < 0.001) [ 30 ].…”

Endovascular treatment for acute ischemic stroke in patients with versus without atrial fibrillation: a matched-control study

“…Furthermore, intravenous thrombolysis (IVT) is less effective on both recanalization and clinical outcome but also increases the risk of intracranial hemorrhage (ICH) in patients with AF. The poor response to IVT could be partly explained by the pathophysiology of AF-related stroke, such as the gaps between patients with and without AF in terms of embolic size and components, collateral status, infarct core volume, and stroke progression [ 13 , 14 ].…”

Comparison of Different Dosages of Alteplase in Atrial Fibrillation–Related Acute Ischemic Stroke After Intravenous Thrombolysis: A Nationwide, Multicenter, Prospective Cohort Study in Taiwan

“… 9 , 10 Despite receiving intravenous thrombolysis (IVT) treatment, patients with AF‐related acute ischemic stroke had poorer functional outcomes and higher hemorrhagic transformation risk. 11 , 12 In addition, compared with White patients with AF, Asian patients with AF had a higher incidence of stroke 13 , 14 and up to 2‐ to 4‐fold higher risk of intracranial bleeding. 15 , 16 , 17 , 18 …”