In this episode, I’ll discuss the 2026 AHA Stroke Guideline changes to how contraindications to thrombolytics are presented.
The data to support contraindications to thrombolytic therapy for acute ischemic stroke is limited to case reports and common sense concerning what patient characteristics might increase the risk of intracerebral hemorrhage or major bleeding.
With the data being so limited and randomized trials to examine risk factors unethical or not feasible, this leads to some inconsistencies between clinicians on what might be considered an absolute contraindication to thrombolysis vs a relative contraindication vs a scenario where the benefit of thrombolysis outweighs the risk of bleeding.
Previous versions of the acute ischemic stroke guidelines used an assessment of contraindications that was rigid and functioned essentially as a checklist. In this 2026 version, the guideline authors have provided a gradient of risk to better reflect how clinicians weigh risk:benefit in actual practice.
The authors use a color-coded gradient to describe this risk in Table 8 of the new guidelines.
The table starts with the color blue which represents conditions which the guideline authors feel the benefits of thrombolytics generally outweight the increased risk of bleeding. This category includes patients with a history of GI bleeding, a history of MI, uncertainty of diagnosis aka ‘stroke mimic’, and an unruptured intracranial aneurysm.
The next color on the risk gradient is orange, and this represents conditions that are relative contraindications to thrombolytics. This category includes patients with a pre-existing disability, recent direct oral anticoagulant (DOAC) exposure, an ischemic stroke within the past 3 months, prior history of intracranial hemorrhage, recent dural puncture, arterial puncture, traumatic brain injury, neurosurgery, non-CNS major trauma, STEMI or GI bleeding, and intracranial arteial dissection. It should be noted there is considerable nuance given in the table to what counts as a DOAC exposure including the timing of last dose, renal function, stroke severity, and the availability of endovascular techniques.
The final color on the risk gradient is red, and this represents conditions that are absolute contraindications to thrombolytics. This category includes patients with hemorrhage on CT scan, intra-axial neoplasm, recent acute spinal cord injury, recent neurosurgery or moderate to severe traumatic brain injury, severe coagulopathy including thrombocytopenia, and infective endocarditis. It should be noted the guideline authors suggest that in the absence of known recent heparin or warfarin use, thrombolytics can be started before an INR or PTT value is available, and if it comes back elevated the infusion can be stopped.
While this represents a positive development in the guidelines as they now more closely reflect how clinicians make these risk:benefit decisions in clinical practice, assessing a patient’s potential contraindications to thrombolytic therapy remains a complicated process in which a pharmacist can add considerable value to the patient care team with prompt and accurate assessments.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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