Patients presenting with acute ischaemic stroke

The AHA Guidelines for the Early Management of Patients with Acute Ischemic Stroke recommend that recombinant tissue-type plasminogen activator should not be administered to people who take NOACs unless sensitive laboratory tests are normal or the patient has not received a dose of these agents for >48 hours.

If the participant is within 4.5 hour window of ischemic stroke symptom onset or patient last known well, clinicians may to choose to unblind to decide on the appropriateness of starting thrombolysis. Alternatively, if it is possible to obtained rivaroxaban-calibrated anti-Xa level in this time period, clinicians may use this information to decide on the appropriateness of starting thrombolysis.

Endovascular treatment with clot extraction can proceed whether or not the participant is receiving rivaroxaban without the need to unblind.

If the participant does not need long-term anticoagulation or dual antiplatelet therapy after an acute ischaemic stroke, the study medication can be restarted.

The decision of when to restart the study medication needs to be balanced by the risk of haemorrhagic transformation.

Consideration should be given to the type of event (TIA or minor stroke versus intermediate or major stroke), time from stroke onset, and presence of factors associated with increased haemorrhage risk (uncontrolled blood pressure, hyperglycaemia, thrombocytopenia, previous haemorrhagic stroke, and thrombolytic treatment). In general, guidelines support withholding oral anticoagulation until 1-3 days after minor stroke or TIA, 1 week after moderate stroke, 2 weeks or more after major stroke among individuals with non-valvular atrial fibrillation.