Candelaresi Paolo, Iannuzzi Angela, Servillo Giovanna, Gottilla Rossella
Division of Neurology and Stroke Unit, AORN Cardarelli, Via Antonio Cardarelli 9, 80128 Naples, Italy.
Emergency Room and Observation Unit, AORN Cardarelli, Via Antonio Cardarelli 9, 80128 Naples, Italy.
Eur Heart J Case Rep. 2020 Apr 24;4(3):1-4. doi: 10.1093/ehjcr/ytaa057. eCollection 2020 Jun.
Dabigatran is a direct competitive thrombin inhibitor approved for stroke prevention in non-valvular atrial fibrillation. At full-dose, dabigatran showed similar rates of bleedings and higher efficacy compared to warfarin.
We report a case of acute ischaemic stroke in a patient treated with dabigatran 150 mg b.i.d. for atrial fibrillation. After an off-label treatment with idarucizumab, a humanized monoclonal antibody approved for dabigatran reversal, we performed a successful intravenous thrombolysis (IVT). Transoesophageal echocardiography showed a left atrial appendage (LAA) thrombus, despite full-dose dabigatran and an adequate therapy adherence.
There are few cases of LAA thrombus during dabigatran treatment reported in literature till date. We analyse the possible pathogenetic mechanisms involved in dabigatran failure, including drug interactions and unexpected genetic variations interfering with dabigatran serum levels suggesting periodical assessment of direct Oral Anticoagulant levels. Furthermore, we confirm initial reports of safety and efficacy of intravenous thrombolysis after idarucizumab, in case of dabigatran failure.
达比加群是一种直接竞争性凝血酶抑制剂，已被批准用于非瓣膜性心房颤动的卒中预防。与华法林相比，达比加群全剂量使用时出血发生率相似，但疗效更高。
我们报告一例接受达比加群150mg每日两次治疗心房颤动的患者发生急性缺血性卒中的病例。在用已被批准用于逆转达比加群作用的人源化单克隆抗体艾达赛珠单抗进行了超说明书治疗后，我们成功地进行了静脉溶栓治疗（IVT）。经食管超声心动图显示尽管使用了全剂量达比加群且患者治疗依从性良好，但仍存在左心耳（LAA）血栓。
迄今为止，文献报道的达比加群治疗期间发生LAA血栓的病例很少。我们分析了达比加群治疗失败可能涉及的发病机制，包括药物相互作用以及影响达比加群血清水平的意外基因变异，提示应定期评估直接口服抗凝剂水平。此外，我们证实了在达比加群治疗失败的情况下，使用艾达赛珠单抗后进行静脉溶栓治疗的安全性和有效性的初步报告。
