What are the anticoagulant orders for a patient with a history of ischemic cerebrovascular accident (CVA) status post tissue plasminogen activator (tPA) (tnk)

From the Guidelines

For a patient with an ischemic stroke (CVA) who has received TNK (tenecteplase) thrombolytic therapy, anticoagulation should be delayed for 24 hours after TNK administration, and then aspirin 81-325 mg daily should be started, with consideration of direct oral anticoagulants (DOACs) like apixaban 5 mg twice daily or rivaroxaban 20 mg daily after 3-14 days for patients with atrial fibrillation or other cardioembolic sources, as recommended by the most recent guidelines 1. The management of anticoagulation in patients with ischemic stroke who have received thrombolytic therapy is crucial to balance the risk of recurrent stroke and hemorrhagic conversion.

• The initial delay in anticoagulation is based on the risk of hemorrhagic transformation, which is highest in the first few days after receiving thrombolytic therapy.
• The choice of anticoagulant and the timing of its initiation depend on the individual patient's risk factors, including the presence of atrial fibrillation or other cardioembolic sources.
• The use of DOACs is preferred over warfarin due to their more predictable pharmacokinetics and lower risk of bleeding complications, as stated in the 2024 ESC guidelines for the management of atrial fibrillation 1. Some key considerations in the management of anticoagulation in these patients include:
• The risk of stroke and bleeding, which should be assessed using validated risk scores such as the CHA2DS2-VASc score.
• The need for bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) in patients who require interruption of anticoagulation for procedures.
• The importance of regular monitoring of anticoagulation therapy to minimize the risk of bleeding complications. Overall, the management of anticoagulation in patients with ischemic stroke who have received thrombolytic therapy requires a careful balance of the risks and benefits of anticoagulation, and should be individualized based on the patient's specific clinical characteristics and risk factors, as recommended by the most recent guidelines 1.

From the Research

Anticoagulant Orders for Ischemic CVA s/p TNK

• The management of patients with ischemic stroke who are already on anticoagulation for atrial fibrillation can be complex, with varying practice patterns among clinicians 2.
• Studies have shown that direct oral anticoagulants (DOACs) may have a better prognosis than warfarin after ischemic stroke, with lower risks of mortality and recurrent stroke 3.
• The choice of anticoagulant agent may depend on various factors, including the patient's history of stroke or transient ischemic attack, and the presence of other comorbidities such as coronary artery disease 4, 5.
• In patients with subclinical atrial fibrillation and a history of stroke or transient ischemic attack, apixaban may be considered for secondary stroke prevention, with a 7% absolute risk reduction in stroke or systemic embolism over 3.5 years 6.
• Rivaroxaban has also been shown to reduce the combined end point of ischemic stroke or intracranial hemorrhage in patients with nonvalvular atrial fibrillation and previous stroke or transient ischemic attack, without an increase in major bleeding risk 5.
• The decision to switch or add anticoagulant agents in patients who experience ischemic stroke while on anticoagulation should be individualized, taking into account the patient's specific clinical characteristics and the potential benefits and risks of different treatment strategies 2.