Effect of alteplase use on outcomes in patients with atrial fibrillation: Analysis of the initiation of anticoagulation after cardioembolic stroke study

Shadi Yaghi, Eva Mistry, Adam de Havenon, Christopher R. Leon Guerrero, Amre Nouh, Ava L. Liberman, James Giles, Angela Liu, Muhammad Nagy, Ashutosh Kaushal, Idrees Azher, Brian Mac Grory, Hiba Fakhri, Kiersten Brown Espaillat, Syed Daniyal Asad, Hemanth Pasupuleti, Heather Martin, Jose Tan, Manivannan Veerasamy, Charles EsenwaNatalie Cheng, Khadean Moncrieffe, Iman Moeini-Naghani, Mithilesh Siddu, Erica Scher, Tushar Trivedi, Teddy Wu, Muhib Khan, Salah Keyrouz, Karen Furie, Nils Henninger

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1 Scopus citations


BACKGROUND: Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90-day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)-related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. METHODS AND RESULTS: We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90-day mortality. There were 1889 patients (90.6%) who had 90-day follow-up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57-3.17) but reduced risk of 90-day mortality (OR, 0.58; 95% CI, 0.39-0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90-day mortality (OR, 0.68; 95% CI, 0.45-1.04). CONCLUSIONS: Alteplase reduced 90-day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.

Original languageEnglish (US)
Article numbere020945
JournalJournal of the American Heart Association
Issue number15
StatePublished - Aug 3 2021


  • Alteplase
  • Atrial fibrillation
  • Mortality
  • Stroke
  • Thrombectomy

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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