Anticoagulants for acute ischaemic stroke
Department of Clinical Neurosciences, University of Edinburgh, Neurosciences Trials Unit, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU. Cochrane database of systematic reviews (Online)
(Impact Factor: 6.03).
02/2008; 3(4):CD000024. DOI: 10.1002/14651858.CD000024.pub3
Millions of people around the world have strokes every year. Most strokes take place when a blood clot blocks a blood vessel leading to the brain. Without a proper blood supply, the brain quickly suffers damage, which can be permanent. The damage from a stroke can cause arm or leg weakness, or difficulties with language or vision. Strokes are sometimes fatal, but will more often leave the survivor unable to do the things that they used to do. Because strokes are common and cause such damage, researchers are trying to find ways to get rid of the blood clot soon after the stroke happens. One way to do this is with blood thinning drugs called anticoagulants. If anticoagulants work, the bad effects of the stroke might be avoided. The main problem with anticoagulants is that they can cause bleeding, which can sometimes be very serious. This systematic review was designed to find out whether people treated with anticoagulants soon after having a stroke got better or not, and whether they had problems with bleeding. There is a lot of information in this systematic review - 23,748 people with stroke have been involved in 24 included randomised trials to answer this question. People treated with anticoagulants did not have less long-term disability, and experienced more bleeding. Anticoagulant treated patients had less chance of developing blood clots in their legs and in their lungs following their stroke, but these benefits were offset by the increased number of bleeds. This review did not provide any evidence that the early use of anticoagulants is of overall benefit to people with strokes caused by blood clots. More research is needed to find out if there are ways to select the people with stroke who will benefit from anticoagulants without suffering the bleeding complications.
Available from: V. Rohan
- "When deciding on the timing of starting full anticoagulant therapy, one must consider the risk of the hemorrhagic transformation of infarction foci with regard to size and location. The benefit of early anticoagulant therapy versus a delayed start has not been proven . Secondary prevention with ASA alone has little effect, and the risk of major bleeding is not significantly different from OA . "
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ABSTRACT: Primary and secondary prevention of ischemic stroke represents a significant part of stroke management and health care. Although there are official guidelines concerning stroke management, new knowledge are introduced to them with a slight delay. This article provides an overview of current information on primary and secondary prevention of ischemic stroke. It summarizes information especially in the field of cardioembolic stroke, the use of new anticoagulants and the management of carotid stenosis based on the results of recent clinical studies. The optimal approach in stroke management is to follow these recommendations, to know new strategies and to apply an individual personalized approach in our clinical decisions.
Available from: M. Stecker
- "Despite the frequency and serious nature of these complications, there is much controversy about diagnosis and treatment [3-6]. Although universal prophylaxis of patients with ischemic stroke using subcutaneous heparin or low molecular weight heparin has been recommended in patients where the risk of hemorrhage is low [6, 7], at least some guidelines have suggested that this treatment may not be effective [3, 8] or may lead to increased risk of hemorrahge . The evidence and recommendations regarding the prophylactic treatment in patients with intracranial hemorrhage is even more confusing . "
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Deep venous thrombosis (DVT) and pulmonary embolus (PE) are serious problems for patients admitted to the hospital with stroke, subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and transient ischemic attack (TIA). The purpose of this paper is to further understand the factors that place certain patients at increased risk of DVT/PE.
At a 600 bed hospital, a retrospective analysis of data from 2613 patients admitted with a diagnosis of stroke, SAH, ICH or TIA in the time range 1/2008 through 3/2012 was carried out. The data was taken from the hospital’s Get with the Guidelines database and included 28 variables. These included initial NIH stroke scale, length of stay, heart failure, ambulatory by day 2 after admission, altered mental status,and renal failure among others. Multiple analyses were carried out to determine whether there were univariable or multivariable effects of any of the factors on the risk for DVT/PE.
The risk of DVT/PE was highest in patients with SAH and ICH and smallest with TIA. Multivariable analyses were performed and revealed only altered level of consciousness or heart failure as significant risks for DVT/PE. With the limited available data, administration of subcutaneous heparin or other chemoprophylaxis did not reduce the risk of DVT/PE.
Although many of the variables used to describe the stroke patient are correlated, in multivariable analyses only heart failure and altered level of consciousness were important risk factors for DVT/PE. The risk of DVT/PE was 7 fold greater in patients in patients with both of these risk factors.
Available from: PubMed Central
- "In a Cochrane meta-analysis, the use of subcutaneous and intravenous unfractionated heparin, low-molecular-weight heparins, subcutaneous and intravenous heparinoids, oral vitamin K antagonists, and specific thrombin inhibitors was associated with a highly significant reduction in the risk of DVT in patients with ischemic stroke (OR, 0.21; 95% CI, 0.15–0.29), although the majority of DVTs detected were subclinical and asymptomatic . However, the International Stroke Trial showed that the prevention of recurrent ischemic stroke by subcutaneous administration of unfractionated heparin (5000 U or 12,500 U twice daily) was offset by a proportional increase in the rate of intracranial hemorrhagic events, resulting in the absence of a net benefit from this preventive treatment . "
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ABSTRACT: Opinion statement
The risk of deep vein thrombosis (DVT) after stroke is increased in patients with restricted mobility, a previous history of DVT, dehydration, or comorbidities such as malignant diseases or clotting disorders. Patients with an increased risk of DVT should receive prophylactic treatment. To reduce the chance of DVT, patients should be mobilized as soon as possible and should be kept well hydrated. Anti-embolism stockings cannot be recommended, because they have been demonstrated not useful for preventing DVT or pulmonary embolism in patients with stroke, and they are associated with a significantly increased risk of skin breaks. The usefulness of intermittent pneumatic compression is currently under study in a randomized clinical trial. Treatment with subcutaneously administered low-dose unfractionated heparin is preferred to unfractionated heparin and may be considered in patients with ischemic stroke if the risk of DVT is estimated to be higher than the risk of hemorrhagic complications. Aspirin may also be effective for patients with ischemic stroke who have contraindications to anticoagulants, although direct comparisons with anticoagulants are not available. In patients with intracerebral hemorrhage, low-dose subcutaneous low-molecular-weight heparin is probably safe after documentation of cessation of active bleeding, and may be considered on an individual basis after 3 to 4 days from stroke onset.
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