Double-blind randomised trial of Org 10172 low-molecular-weight heparinoid in prevention of deep-vein thrombosis in thrombotic stroke

Anticoagulants for thrombosis prophylaxis in acutely ill patients admitted to hospital: systematic review and network meta-analysis

OBJECTIVE

To assess the benefits and harms of different types and doses of anticoagulant drugs for the prevention of venous thromboembolism in patients who are acutely ill and admitted to hospital.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Cochrane CENTRAL, PubMed/Medline, Embase, Web of Science, clinical trial registries, and national health authority databases. The search was last updated on 16 November 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Published and unpublished randomised controlled trials that evaluated low or intermediate dose low-molecular-weight heparin, low or intermediate dose unfractionated heparin, direct oral anticoagulants, pentasaccharides, placebo, or no intervention for the prevention of venous thromboembolism in acutely ill adult patients in hospital.

MAIN OUTCOME MEASURES

Random effects, bayesian network meta-analyses used four co-primary outcomes: all cause mortality, symptomatic venous thromboembolism, major bleeding, and serious adverse events at or closest timing to 90 days. Risk of bias was also assessed using the Cochrane risk-of-bias 2.0 tool. The quality of evidence was graded using the Confidence in Network Meta-Analysis framework.

RESULTS

44 randomised controlled trials that randomly assigned 90 095 participants were included in the main analysis. Evidence of low to moderate quality suggested none of the interventions reduced all cause mortality compared with placebo. Pentasaccharides (odds ratio 0.32, 95% credible interval 0.08 to 1.07), intermediate dose low-molecular-weight heparin (0.66, 0.46 to 0.93), direct oral anticoagulants (0.68, 0.33 to 1.34), and intermediate dose unfractionated heparin (0.71, 0.43 to 1.19) were most likely to reduce symptomatic venous thromboembolism (very low to low quality evidence). Intermediate dose unfractionated heparin (2.63, 1.00 to 6.21) and direct oral anticoagulants (2.31, 0.82 to 6.47) were most likely to increase major bleeding (low to moderate quality evidence). No conclusive differences were noted between interventions regarding serious adverse events (very low to low quality evidence). When compared with no intervention instead of placebo, all active interventions did more favourably with regard to risk of venous thromboembolism and mortality, and less favourably with regard to risk of major bleeding. The results were robust in prespecified sensitivity and subgroup analyses.

CONCLUSIONS

Low-molecular-weight heparin in an intermediate dose appears to confer the best balance of benefits and harms for prevention of venous thromboembolism. Unfractionated heparin, in particular the intermediate dose, and direct oral anticoagulants had the least favourable profile. A systematic discrepancy was noted in intervention effects that depended on whether placebo or no intervention was the reference treatment. Main limitations of this study include the quality of the evidence, which was generally low to moderate due to imprecision and within-study bias, and statistical inconsistency, which was addressed post hoc.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020173088.

Bridging Therapy With Heparin Before Starting Rivaroxaban in Ischemic Stroke or Transient Ischemic Attack With Non-Valvular Atrial Fibrillation

BACKGROUND

The present observational study aimed to clarify the association between bridging therapy with heparin before starting rivaroxaban and clinical outcomes after ischemic stroke or transient ischemic attack (TIA) in patients with non-valvular atrial fibrillation (NVAF).Methods and Results:Patients with NVAF who experienced acute ischemic stroke or TIA of the middle cerebral artery territory and started rivaroxaban within 30 days after onset were enrolled and were followed up for 90 days. Outcome measures were ischemic events, major bleeding, their composite, and death or disability 90 days after onset. Ischemic events were defined as ischemic stroke, TIA, and systemic embolism. Of 1,308 analyzed patients, 638 received bridging therapy with unfractionated or low-molecular-weight heparin with a median of 10,000 IU/day. Associations between bridging therapy and ischemic events or major bleeding were not statistically significant individually, but the association between bridging therapy and their composite was statistically significant (multivariable-adjusted hazard ratio, 1.80; 95% confidence interval, 1.01-3.29). The association between bridging therapy and death or disability 90 days after onset was not statistically significant.

CONCLUSIONS

The composite of ischemic events and major bleeding was more frequent in patients with NVAF who received bridging therapy with low-dose heparin than in those who started treatment directly with rivaroxaban after ischemic stroke or TIA.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Stroke is the third leading cause of early death worldwide. Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Patient outcomes might be improved if they are offered anticoagulants that reduce their risk of developing new blood clots and do not increase the risk of bleeding. This is an update of a Cochrane Review first published in 1995, with updates in 2004, 2008, and 2015.

OBJECTIVES

To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) for people with acute presumed or confirmed ischaemic stroke. Our hypotheses were that, compared with a policy of avoiding their use, early anticoagulation would be associated with: • reduced risk of death or dependence in activities of daily living a few months after stroke onset; • reduced risk of early recurrent ischaemic stroke; • increased risk of symptomatic intracranial and extracranial haemorrhage; and • reduced risk of deep vein thrombosis and pulmonary embolism.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (August 2021); the Cochrane Database of Systematic Reviews (CDSR); the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 7), in the Cochrane Library (searched 5 August 2021); MEDLINE (2014 to 5 August 2021); and Embase (2014 to 5 August 2021). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies.

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data. We assessed the overall certainty of the evidence for each outcome using RoB1 and GRADE methods.

MAIN RESULTS

We included 28 trials involving 24,025 participants. Quality of the trials varied considerably. We considered some studies to be at unclear or high risk of selection, performance, detection, attrition, or reporting bias. Anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence is related to effects of anticoagulant therapy initiated within the first 48 hours of onset. No evidence suggests that early anticoagulation reduced the odds of death or dependence at the end of follow-up (odds ratio (OR) 0.98, 95% confidence interval (CI) 0.92 to 1.03; 12 RCTs, 22,428 participants; high-certainty evidence). Similarly, we found no evidence suggesting that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (OR 0.99, 95% CI 0.90 to 1.09; 22 RCTs, 22,602 participants; low-certainty evidence) during the treatment period. Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.75, 95% CI 0.65 to 0.88; 12 RCTs, 21,665 participants; moderate-certainty evidence), it was also associated with an increase in symptomatic intracranial haemorrhage (OR 2.47; 95% CI 1.90 to 3.21; 20 RCTs, 23,221 participants; moderate-certainty evidence). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60, 95% CI 0.44 to 0.81; 14 RCTs, 22,544 participants; high-certainty evidence), but this benefit was offset by an increase in extracranial haemorrhage (OR 2.99, 95% CI 2.24 to 3.99; 18 RCTs, 22,255 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, four new relevant studies have been published, and conclusions remain consistent. People who have early anticoagulant therapy after acute ischaemic stroke do not demonstrate any net short- or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis, and pulmonary embolism but increased bleeding risk. Data do not support the routine use of any of the currently available anticoagulants for acute ischaemic stroke.

Preoperative prevalence of deep vein thrombosis in patients scheduled to have surgery for degenerative musculoskeletal disorders

Background

Although the incidence of symptomatic pulmonary thromboembolism after elective surgery for degenerative musculoskeletal disorders is comparatively low, it is extremely detrimental to both patients and health-care providers. Therefore, its prevention is mandatory. We aimed to perform a cross-sectional analysis of deep venous thrombosis (DVT) before elective surgery for degenerative musculoskeletal disorders, including total knee arthroplasty (TKA), total hip arthroplasty (THA), and spinal surgery, and identify the factors associated with the incidence of preoperative DVT.

Methods

The clinical data of patients aged ≥ 30 years who underwent TKA or THA, and spine surgery for lumbar or cervical degenerative disorders at our institution were retrospectively collected. D-dimer levels were measured preoperatively in all the patients scheduled for surgery. For the patients with D-dimer levels ≥ 1 µg/mL or who were determined by their physicians to be at high risk of DVT, the lower extremity vein was preoperatively examined for DVT on ultrasonography.

Results

Overall, we retrospectively evaluated 1236 consecutive patients, including 701 men and 535 women. Of the patients, 431 and 805 had D-dimer levels ≥ 1 and < 1 µg/mL, respectively. Of 683 patients who underwent lower extremity ultrasonography, 92 had proximal (n = 7) and distal types (n = 85) of DVT. The preoperative prevalence of DVT was 7.4 %. No patient had the incidence of postoperative symptomatic venous thromboembolism. A multivariate analysis revealed that age ≥ 80 years (odds ratio [OR], 95 % confidence interval [CI]: 2.8, 1.1–7.3), knee surgery (2.1, 1.1–4.0), American Society of Anesthesiologists (ASA) grade 2 (2.8, 1.2–6.8), ASA grades 3 or 4 (3.1, 1.0–9.4), and malignancy (1.9, 1.1–3.2) were significantly associated with DVT incidence.

Conclusions

This is the first study to conduct a cross-sectional analysis of preoperative DVT data of patients scheduled for elective surgery for degenerative musculoskeletal disorders. Although whether screening for preoperative DVT is needed to prevent postoperative symptomatic pulmonary thromboembolism remains to be clarified, our data suggested that DVT should be noted before surgery in the patients with advanced age, knee surgery, high ASA physical status, and malignancy.

Individualized predictions of early isolated distal deep vein thrombosis in patients with acute ischemic stroke: a retrospective study

Background

Although isolated distal deep vein thrombosis (IDDVT) is a clinical complication for acute ischemic stroke (AIS) patients, very few clinicians value it and few methods can predict early IDDVT. This study aimed to establish and validate an individualized predictive nomogram for the risk of early IDDVT in AIS patients.

Methods

This study enrolled 647 consecutive AIS patients who were randomly divided into a training cohort (n = 431) and a validation cohort (n = 216). Based on logistic analyses in training cohort, a nomogram was constructed to predict early IDDVT. The nomogram was then validated using area under the receiver operating characteristic curve (AUROC) and calibration plots.

Results

The multivariate logistic regression analysis revealed that age, gender, lower limb paralysis, current pneumonia, atrial fibrillation and malignant tumor were independent risk factors of early IDDVT; these variables were integrated to construct the nomogram. Calibration plots revealed acceptable agreement between the predicted and actual IDDVT probabilities in both the training and validation cohorts. The nomogram had AUROC values of 0.767 (95% CI: 0.742–0.806) and 0.820 (95% CI: 0.762–0.869) in the training and validation cohorts, respectively. Additionally, in the validation cohort, the AUROC of the nomogram was higher than those of the other scores for predicting IDDVT.

Conclusions

The present nomogram provides clinicians with a novel and easy-to-use tool for the prediction of the individualized risk of IDDVT in the early stages of AIS, which would be helpful to initiate imaging examination and interventions timely.

Short-Term and Long-Term Safety and Efficacy of Treatment of Acute Ischemic Stroke with Low-Molecular-Weight Heparin: Meta-Analysis of 19 Randomized Controlled Trials

OBJECTIVE

Currently, it remains controversial about guidelines for the application of low-molecular-weight heparin (LMWH) in patients with acute ischemic stroke (AIS). Therefore this meta-analysis was carried out, aiming to systematically investigate the short-term and long-term safety and efficacy of LMWH in AIS patients.

METHODS

Three electronic databases-PubMed, Embase database, and Cochrane library-were comprehensively retrieved by 2 investigators independently. Finally, a total of 19 randomized controlled trials were enrolled for analysis. The safety endpoints in this study included all-cause mortality and the risk of bleeding (major, minor, or cerebral hemorrhage). The efficacy endpoints were the prevention of deep vein thrombosis (DVT) and recurrent stroke.

RESULTS

The application of LMWH led to a decreased risk of DVT, and there was no significant association in all-cause mortality or recurrent stroke. According to age-stratified analyses, the risk of all-cause mortality increased by 39% (risk ratio 1.39, 1.03-1.88; I² 0%) in AIS patients aged older than 70 years who used LMWH for 14 days, and there was no significant effect on preventing DVT (risk ratio 0.69, 0.14-3.52; I² 26.4%) in patients aged younger than 70 years old within 3 months. Moreover, enoxaparin and danaparoid were more effective at preventing DVT, regardless of age.

CONCLUSIONS

To sum up, on the basis of limited studies available currently, the early use of LMWH in AIS patients aged older than 70 years should be cautious because it may increase the risk of all-cause mortality. For patients younger than 70 years old, the early use of LMWH significantly reduces the short-term risk of DVT, but there is no significant relationship in the long term. In terms of DVT prevention, enoxaparin and danaparoid are probably more effective. Nonetheless, more future randomized controlled trials are warranted to verify and support this conclusion.

Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania

OBJECTIVE

Given the high post-stroke mortality and disability and paucity of data on the quality of stroke care in Sub-Saharan Africa, we sought to characterize the implementation of stroke-focused treatments and 90-day outcomes of neuroimaging-confirmed stroke patients at the largest referral hospital in Tanzania.

DESIGN

Prospective cohort study.

SETTING

Muhimbili National Hospital (MNH) in Dar es Salaam, July 2016-March 2017.

PARTICIPANTS

Adults with new-onset stroke (<14 days), confirmed by head CT, admitted to MNH.

MAIN OUTCOMES MEASURES

Modified Rankin scale (mRS) and vital status.

RESULTS

Of 149 subjects (mean age 57; 48% female; median NIH stroke scale (NIHSS) 19; 46% ischemic stroke; 54% hemorrhagic), implementation of treatments included: dysphagia screening (80%), deep venous thrombosis prophylaxis (0%), aspirin (83%), antihypertensives (89%) and statins (95%). There was limited ability to detect atrial fibrillation and carotid artery disease and no acute thrombolysis or thrombectomy. Of ischemic subjects, 19% died and 56% had severe disability (mRS 4-5) at discharge; 49% died by 90 days. Of hemorrhagic subjects, 33% died and 49% had severe disability at discharge; 50% died by 90 days. In a multivariable model, higher NIHSS score but not dysphagia, unconsciousness, or patient age was predictive of death by 90 days.

CONCLUSIONS

The 90-day mortality of stroke presenting at MNH is 50%, much higher than in higher income settings. Although severe stroke presentations are a major factor, efforts to improve the quality of care and prevent complications of stroke are urgently needed. Acute stroke interventions with low number needed to treat represent challenging long-term goals.

Venous thromboembolism prophylaxis using the Caprini score

Venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT) is one of the leading causes of preventable cardiovascular disease in the United States (US) and is the number one preventable cause of death following a surgical procedure. Post-operative VTE is associated with multiple short and long-term complications. We will focus on reviewing the many faces of VTE in detail as they represent common challenging scenarios in clinical practice.

Elevated Blood Urea Nitrogen/Creatinine Ratio Is Associated with Venous Thromboembolism in Patients with Acute Ischemic Stroke

Objective

Although venous thromboembolism (VTE) is frequently related to dehydration, the impact of dehydration on VTE in acute ischemic stroke (AIS) is not clear. This study investigated whether dehydration, as measured by blood urea nitrogen (BUN)/creatinine (Cr) ratio, influences the occurrence of VTE in patients with AIS.

Methods

This is a retrospective study of patients with AIS between January 2012 and December 2013. Patients with newly diagnosed AIS who experienced prolonged hospitalization for at least 4 weeks were included in this study.

Results

Of 182 patients included in this study, 17 (9.3%) suffered VTE during the follow-up period; in two cases, VTE was accompanied by deep vein thrombosis and pulmonary embolism. Patients with VTE were more frequently female and had higher National Institutes of Health Stroke Scale (NIHSS) score, more lower limb weakness, and elevated blood urea nitrogen BUN/Cr ratio on admission. In a multivariate analysis, BUN/Cr ratio >15 (odds ratio [OR] 8.75) and severe lower limb weakness (OR 4.38) were independent risk factors for VTE.

Conclusion

Dehydration on admission in cases of AIS might be a significant independent risk factor for VTE.

Effectiveness of 7-day versus weekday-only rehabilitation for stroke patients in an acute-care hospital: a retrospective cohort study

PURPOSE

Early rehabilitation is widely recommended for acute-stroke patients. We tested the hypothesis that the functional prognosis of stroke patients receiving daily early rehabilitation in a clinical practice setting is generally better than that of patients receiving rehabilitation only on weekdays.

MATERIALS AND METHODS

We analyzed hospitalized patients who experienced either cerebral infarctions or cerebral hemorrhages and subsequently underwent rehabilitation at our hospital between October 2010 and September 2014. We examined the association between training frequency and activities of daily living improvements, as indicated by the Barthel Index (BI) effectiveness.

RESULTS

In total, 661 patients with cerebral infarctions and 245 with intracerebral hemorrhages (ICHs) were analyzed. The BI effectiveness was highest for patients receiving high-frequency therapy following cerebral infarction. In addition, multiple linear regression analysis indicated that BI effectiveness was significantly and positively correlated with high-frequency therapy (coefficient, 0.072; 95% confidence interval, 0.019-0.126; p < 0.01) in patients with cerebral infarctions. There was no significant difference in BI effectiveness between therapeutic protocols for patients with ICHs.

CONCLUSION

This retrospective cohort study demonstrated that extensive therapy can result in functional recovery in patients with cerebral infarctions. Implications for Rehabilitation Early intervention with intensive rehabilitation therapy is important for improving the functional recovery of patients during acute-care hospitalization. Few acute hospitals provide more than 2 h of daily rehabilitation for patients with acute stroke. In a daily clinical practice setting, this clinical study demonstrates a direct relationship between early intervention with intensive rehabilitation therapy and good functional recovery of stroke patients in an acute ward.

European Stroke Organisation (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke

Background

Venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism is a frequent complication in immobile patients with acute ischemic stroke. This guideline document presents the European Stroke Organisation guidelines for the prophylaxis of VTE in immobile patients with acute ischaemic stroke. Guidelines for haemorrhagic stroke have already been published.

Methods

A multidisciplinary group identified related questions and developed its recommendations based on evidence from randomised controlled trials using the Grading of Recommendations Assessment, Development, and Evaluation approach. This guideline document was reviewed within the European Stroke Organisation and externally and was approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee.

Results

We found mainly moderate quality evidence comprising randomised controlled trials and systematic reviews evaluating graduated compression stockings (GCS), intermittent pneumatic compression (IPC) and prophylactic anticoagulation with unfractionated (UFH) and low molecular weight heparins (LMWH) and heparinoids, but no randomised trials evaluating neuromuscular electrical stimulation (NES). We recommend that clinicians should use IPC in immobile patients, but that they should not use GCS. Prophylactic anticoagulation with UFH (5000U ×2, or ×3 daily) or LMWH or heparinoid should be considered in immobile patients with ischaemic stroke in whom the benefits of reducing the risk of VTE is high enough to offset the increased risks of intracranial and extracranial bleeding associated with their use. Where a judgement has been made that prophylactic anticoagulation is indicated LMWH or heparinoid should be considered instead of UFH because of its greater reduction in risk of DVT, the greater convenience, reduced staff costs and patient comfort associated single vs. multiple daily injections but these advantages should be weighed against the higher risk of extracranial bleeding, higher drug costs and risks in elderly patients with poor renal function associated with LMWH and heparinoids.

Conclusions

IPC, UFH or LMWH and heparinoids can reduce the risk of VTE in immobile patients with acute ischaemic stroke but further research is required to test whether NES is effective. The strongest evidence is for IPC. Better methods are needed to help stratify patients in the first few weeks after stroke onset, by their risk of VTE and their risk of bleeding on anticoagulants.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Most ischaemic strokes are caused by a blood clot blocking an artery in the brain. Clot prevention with anticoagulants might improve outcomes if bleeding risks are low. This is an update of a Cochrane review first published in 1995, with recent updates in 2004 and 2008.

OBJECTIVES

To assess the effectiveness and safety of early anticoagulation (within the first 14 days of onset) in people with acute presumed or confirmed ischaemic stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (June 2014), the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews (CDSR), the Database of Reviews of Effects (DARE) and the Health Technology Assessment Database (HTA) (The Cochrane Library 2014 Issue 6), MEDLINE (2008 to June 2014) and EMBASE (2008 to June 2014). In addition, we searched ongoing trials registries and reference lists of relevant papers. For previous versions of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies.

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in people with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted the data.

MAIN RESULTS

We included 24 trials involving 23,748 participants. The quality of the trials varied considerably. The anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Over 90% of the evidence relates to the effects of anticoagulant therapy initiated within the first 48 hours of onset. Based on 11 trials (22,776 participants) there was no evidence that anticoagulant therapy started within the first 14 days of stroke onset reduced the odds of death from all causes (odds ratio (OR) 1.05; 95% confidence interval (CI) 0.98 to 1.12) at the end of follow-up. Similarly, based on eight trials (22,125 participants), there was no evidence that early anticoagulation reduced the odds of being dead or dependent at the end of follow-up (OR 0.99; 95% CI 0.93 to 1.04). Although early anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.76; 95% CI 0.65 to 0.88), it was also associated with an increase in symptomatic intracranial haemorrhages (OR 2.55; 95% CI 1.95 to 3.33). Similarly, early anticoagulation reduced the frequency of symptomatic pulmonary emboli (OR 0.60; 95% CI 0.44 to 0.81), but this benefit was offset by an increase in extracranial haemorrhages (OR 2.99; 95% CI 2.24 to 3.99).

AUTHORS' CONCLUSIONS

Since the last version of the review, no new relevant studies have been published and so there is no additional information to change the conclusions. Early anticoagulant therapy is not associated with net short- or long-term benefit in people with acute ischaemic stroke. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis and pulmonary embolism, but increased bleeding risk. The data do not support the routine use of any of the currently available anticoagulants in acute ischaemic stroke.

Prevention of Venous Thromboembolism After Stroke

Venous thromboembolism (VTE) is a common complication following acute ischemic and hemorrhagic stroke. Pulmonary embolism (PE), the most serious consequence of deep vein thrombosis (DVT), can result in significant morbidity and death. Patients with stroke are at particular risk because of limb paralysis, prolonged bed rest, and increased prothrombotic activity. Preventive measures should be taken at all levels of care and can include mechanical calf compression, antiplatelet agents, and the use of anticoagulants such as heparin and low molecular weight heparin. Prevention of VTE should be incorporated into all stroke care pathways.

Thrombo-prophylaxis in acutely ill medical and critically ill patients

Thrombo-prophylaxis has been shown to reduce the incidence of pulmonary embolism (PE) and mortality in surgical patients. The purpose of this review is to find out the evidence-based clinical practice criteria of deep vein thrombosis (DVT) prophylaxis in acutely ill medical and critically ill patients. English-language randomized controlled trials, systematic reviews, and meta-analysis were included if they provided clinical outcomes and evaluated therapy with low-dose heparin or related agents compared with placebo, no treatment, or other active prophylaxis in the critically ill and medically ill population. For the same, we searched MEDLINE, PUBMED, Cochrane Library, and Google Scholar. In acutely ill medical patients on the basis of meta-analysis by Lederle et al. (40 trials) and LIFENOX study, heparin prophylaxis had no significant effect on mortality. The prophylaxis may have reduced PE in acutely ill medical patients, but led to more bleeding events, thus resulting in no net benefit. In critically ill patients, results of meta-analysis by Alhazzani et al. and PROTECT Trial indicate that any heparin prophylaxis compared with placebo reduces the rate of DVT and PE, but not symptomatic DVT. Major bleeding risk and mortality rates were similar. On the basis of MAGELLAN trial and EINSTEIN program, rivaroxaban offers a single-drug approach to the short-term and continued treatment of venous thrombosis. Aspirin has been used as antiplatelet agent, but when the data from two trials the ASPIRE and WARFASA study were pooled, there was a 32% reduction in the rate of recurrence of venous thrombo-embolism and a 34% reduction in the rate of major vascular events.

Rate of deep-vein thrombosis and pulmonary embolism during the care continuum in patients with acute ischemic stroke in the United States

BACKGROUND

Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are frequent and life-threatening complications of ischemic stroke. We evaluated rates of symptomatic DVT/PE, and of in-hospital and post-discharge thromboprophylaxis in patients with acute ischemic stroke (AIS).

METHODS

In a retrospective US database analysis, data were extracted from the Premier Perspective™-i3 Pharma Informatics linked database for patients aged ≥18 years who were hospitalized for ischemic stroke from January 2005 to November 2007, and who had ≥6 months' continuous plan enrollment prior to index hospitalization. Patients discharged to an acute-care facility or with atrial fibrillation were excluded. Prophylaxis was evaluated during index hospitalization and for 14 days' post-discharge. DVT/PE rates were calculated during index hospitalization and up to 30 days post-discharge.

RESULTS

A total of 1524 patients were included; 46.1% received pharmacological and/or mechanical prophylaxis in-hospital (28.3%, 11.4% and 12.3% received unfractionated heparin, enoxaparin and mechanical prophylaxis, respectively). 6.4% of patients received outpatient pharmacological prophylaxis; warfarin was most frequently prescribed (5.9%). Total mean ± standard deviation length of index hospitalization was 3.0 ± 2.5 days. Mean prophylaxis duration in all patients was 0.9 ± 1.5 days in-hospital and 1.7 ± 6.9 days post-discharge. Symptomatic DVT/PE occurred in 25 patients overall (1.64%), with an inpatient rate of 0.98% and an outpatient rate of 0.66%.

CONCLUSIONS

Approximately 1% of patients with AIS experienced symptomatic in-hospital and/or post-discharge DVT/PE. Although 46% received prophylaxis in-hospital, only 6% received prophylaxis in the outpatient setting. This highlights the need for sustained thromboprophylaxis prescribing across the continuum of care.

Venous thromboembolism in the Get With The Guidelines-Stroke acute ischemic stroke population: incidence and patterns of prophylaxis

BACKGROUND

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolus (PE), represents a serious complication in hospitalized ischemic stroke patients. This study examines the incidence of VTE and the patterns of VTE prophylaxis in acute ischemic stroke patients deemed appropriate for VTE prophylaxis (nonambulatory) in the Get With The Guidelines-Stroke (GWTG-S) study.

METHODS

We analyzed data from 149,916 patients who were admitted with acute ischemic stroke and enrolled in GWTG-S from 1259 U.S. hospitals. Patient variables and site characteristics were analyzed in relation to reported administration of VTE prophylaxis.

RESULTS

The overall rate of VTE prophylaxis in the analysis cohort was 93% (139,476/149,916). The median site prophylaxis rate was 95%, and prophylaxis rates ranged from 17% (1 site) to 100% (101 sites). Factors associated with increased likelihood of VTE prophylaxis in the multivariable model included history of atrial fibrillation/flutter, receipt of intravenous or intra-arterial tissue plasminogen activator, and admission to an academic hospital. Increasing age, black race, and a history of peripheral vascular disease, diabetes, or stroke were associated with lower likelihood of prophylaxis. Patients receiving care in the Midwest were less likely to receive prophylaxis compared to other regions.

CONCLUSIONS

Despite a high overall rate of VTE prophylaxis, VTE was found to occur in approximately 3% of GWTG-S patients. Reported rates of VTE prophylaxis differed among hospitals by region and hospital type, and among patients by age, race, and medical comorbidities.

Prevention of Deep Vein Thrombosis and Pulmonary Embolism in Patients With Stroke

Venous thromboembolism (VTE), encompassing deep venous thrombosis and pulmonary embolism, is a potentially fatal but preventable complication of stroke. Reported rates of VTE after stroke have decreased over the last four decades, possibly due to the implementation of stroke units, early mobilization and hydration, and increased early use of antiplatelets. Additional means of thromboprophylaxis in stroke include mechanical methods (ie, compression stockings) to prevent venous stasis and medical therapy including antiplatelets, heparins, and heparinoids. Risk of VTE must be balanced by potential risk of hemorrhagic complications from pharmacotherapy. Unfractionated heparin, low-molecular-weight heparin (LMWH), and danaparoid are acceptable options for chemoprophylaxis though none have shown superior efficacy for VTE prevention without an associated increase in major hemorrhage. The efficacy and timing of pharmacological thromboprophylaxis in hemorrhagic stroke are not well defined. Graduated compression stockings are associated with an increased rate of adverse events and are not recommended and intermittent pneumatic compression stockings require further investigation.

Danaparoid as the prophylaxis for hepatic veno-occlusive disease after allogeneic hematopoietic stem cell transplantation in childhood hematological malignancy

BACKGROUND

Veno-occlusive disease (VOD) is a regimen-related toxicity that occurs in the early phase of hematopoietic stem cell transplantation (HSCT). Therapeutic modalities for established VOD are limited, and severe VOD characterized by multiple organ failure is associated with a fatal prognosis despite intensive supportive care.

PROCEDURE

We analyzed the data of 95 consecutive allogeneic HSCT for childhood hematological malignancies, and assessed the efficacy of our VOD prophylaxis regimen based on danaparoid (n = 48), comparing with historical control regimen based on dalteparin (n = 47).

RESULTS

Eight patients (danaparoid cohort in one; dalteparin cohort in seven) developed VOD on day +30 (median onset, day +22; range, day +11 to day +28) after HSCT. The probability of developing VOD for the danaparoid cohort was 2% (95% CI, 0-6%) and that of the dalteparin cohort was 15% (95% CI, 5-26%). In the Cox hazard proportional model, the danaparoid cohort had a significant advantage over the dalteparin cohort for the prophylaxis of VOD (hazard ratio (HR), 0.0; 95% CI, 0.0-0.3; P < 0.01) without increasing hemorrhagic events.

CONCLUSIONS

Our findings suggest that danaparoid may have promise for the prophylaxis of VOD after allogeneic HSCT and further randomized studies are warranted.

The use of an exclusion-based risk-assessment model for venous thrombosis improves uptake of appropriate thromboprophylaxis in hospitalized medical patients

BACKGROUND

Venous thromboembolism is a common condition in hospitalized medical patients. Numerous studies have demonstrated that low molecular weight heparin significantly reduces this risk but, despite this, the use of thromboprophylaxis remains poor.

AIM

To evaluate the use of an exclusion based risk-assessment model (RAM) for venous thrombosis in improving the uptake of appropriate thromboprophylaxis in hospitalized medical patients.

DESIGN

A survey with a subsequent audit cycle of three separate audits over 36 months.

METHODS

497 hospitalized patients with acute medical conditions on general medical wards were audited at a secondary care centre in London, UK. The survey and subsequent audits were performed by reviewing the notes and medication charts of medical patients, prior to the launch of the RAM and at 12, 28 and 36 months following its introduction.

RESULTS

Prior to launching the RAM, 49% of hospitalized medical patients received appropriate thromboprophylaxis. This did not change 12 months after the RAM was introduced but increased significantly to 71% following formal education of the health care professionals involved in thromboprophylaxis prescription. This improvement was maintained as demonstrated by a subsequent audit 8 months later (75.9%).

CONCLUSION

The introduction of a simple exclusion-based RAM for venous thrombosis in medical patients significantly improved delivery of thromboprophylaxis. The successful uptake of the RAM appears to have been dependent on direct education of those health carers involved in its use. A similar exclusion-based model used nationally could have a significant impact on the burden of VTE currently experienced in the UK.

Guidelines for prevention of venous thromboembolism in immobile patients secondary to neurological impairment

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients and 7% of these cases are due to immobility secondary to a neurological impairment. Many guidelines are available to guide clinicians dealing with medical or surgical patients. However, and with the exception of spinal injuries, no guidelines are available to deal with other neurologically impaired patients at risk of VTE.

AIM

Our study aimed at gathering evidence from the literature to enable us to deal with the main controversial issues of VTE prevention. Guidelines will be formulated.

METHOD

A Clinical Standards Group is responsible for the development of clinical guidelines for the Greater Manchester Neurorehabilitation network with services covering a population of around 3 million. The development of VTE prevention guidelines started with the formulation of the main questions, then gathering evidence from the literature to address these questions. Wide consultation then took place. The guidelines were then put before the group for endorsement.

RESULTS

Answers for the main questions such as duration of thromboprophylaxis, TEDS and antiplatelets drugs use were suggested. The resulting document was summarized as a flow chart for use.

CONCLUSION

We feel that the proposed guidelines are a useful tool for clinicians as they reflect the evidence available from the literature at the moment.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Most ischaemic strokes are caused by blood clots blocking an artery in the brain. Clot prevention with anticoagulants might improve outcome if bleeding risks were low. This is an update of a Cochrane review first published in 1995, and previously updated in 2004.

OBJECTIVES

To assess the effect of anticoagulant therapy versus control in the early treatment (less than 14 days) of patients with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 2 October 2007), and two Internet clinical trials registries for relevant ongoing studies (last searched October 2007).

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in patients with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted the data.

MAIN RESULTS

Twenty-four trials involving 23,748 participants were included. The quality of the trials varied considerably. The anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Based on 11 trials (22,776 participants) there was no evidence that anticoagulant therapy reduced the odds of death from all causes (odds ratio (OR) 1.05; 95% confidence interval (CI) 0.98 to 1.12) at the end of follow up. Similarly, based on eight trials (22,125 participants), there was no evidence that anticoagulants reduced the odds of being dead or dependent at the end of follow up (OR 0.99; 95% CI 0.93 to 1.04). Although anticoagulant therapy was associated with fewer recurrent ischaemic strokes (OR 0.76; 95% CI 0.65 to 0.88), it was also associated with an increase in symptomatic intracranial haemorrhages (OR 2.55; 95% CI 1.95 to 3.33). Similarly, anticoagulants reduced the frequency of pulmonary emboli (OR 0.60; 95% CI 0.44 to 0.81), but this benefit was offset by an increase in extracranial haemorrhages (OR 2.99; 95% CI 2.24 to 3.99).

AUTHORS' CONCLUSIONS

Since the last version of the review, neither of the two new relevant studies have provided additional information to change the conclusions. In patients with acute ischaemic stroke, immediate anticoagulant therapy is not associated with net short or long-term benefit. Treatment with anticoagulants reduced recurrent stroke, deep vein thrombosis and pulmonary embolism, but increased bleeding risk. The data do not support the routine use of any the currently available anticoagulants in acute ischaemic stroke.

Venous thromboembolism prophylaxis and treatment in patients with acute stroke and traumatic brain injury

PURPOSE OF REVIEW

Patients with acute stroke and traumatic brain injury are at risk to develop venous thromboembolism. This review analyzes the available literature to propose guidelines for the prevention and treatment of venous thromboembolism in these groups of patients.

RECENT FINDINGS

In acute ischemic stroke, low-dose low-molecular-weight heparin has the best benefit-risk ratio to prevent venous thromboembolism. Patients with primary intracerebral hemorrhage and traumatic brain injury should receive intermittent pneumatic compression, followed by low-dose low-molecular-weight heparin or unfractioned heparin 3-4 days after stroke onset or 24 h after injury or surgery, respectively, and after cessation of bleeding. Concerning treatment, in patients with deep-vein thrombosis lower doses of heparin are indicated to prevent pulmonary embolism, and a vena cava filter should be considered. In patients with pulmonary embolism, treatment could be more aggressive, because of a high mortality risk.

SUMMARY

Adequate prevention of venous thromboembolism with intermittent pneumatic compression or pharmacological prophylaxis is important. The best treatment of venous thromboembolism remains unclear. In case of pulmonary embolism, more aggressive treatment is warranted.

Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis

BACKGROUND

The effect of anticoagulant prophylaxis on the prevention of deep vein thrombosis (DVT) should include an investigation of both clinical and subclinical DVT. We conducted a systematic review to determine whether anticoagulant prophylaxis reduces the risk of asymptomatic DVT compared to no prophylaxis in at-risk hospitalized medical patients.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched through March 2007 for randomized trials of anticoagulant prophylaxis for the prevention of asymptomatic DVT, assessed by venogram or ultrasound. We assessed four outcomes: all asymptomatic DVT, asymptomatic proximal DVT, major bleeding and mortality. Random effects meta-analyses were performed and results were expressed using relative risk (RR) and 95% confidence intervals (95% CIs).

RESULTS

Four trials including 5516 patients were eligible. Our pooled analysis demonstrated that compared to placebo, anticoagulant prophylaxis was associated with a significantly lower risk of any asymptomatic DVT (RR 0.51; 95% CI 0.39-0.67) and asymptomatic proximal DVT (RR 0.45; 95% CI 0.31-0.65). Anticoagulant prophylaxis was associated with a significantly increased risk of major bleeding compared to placebo (RR 2.00; 95% CI 1.05-3.79). There was no significant difference in the pooled estimate for all-cause mortality. Anticoagulant prophylaxis conferred an absolute risk reduction of any DVT and proximal DVT of 2.6% and 1.8%, respectively, and was associated with a 0.5% absolute risk increase in major bleeding.

CONCLUSIONS

Anticoagulant prophylaxis is effective in preventing asymptomatic DVT in at-risk hospitalized medical patients but is associated with an increased bleeding risk. The therapeutic benefits of anticoagulant prophylaxis appear to outweigh the risks of bleeding.

Guidelines for the Early Management of Adults With Ischemic Stroke

Purpose— Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

Methods— Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

Results— Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists

PURPOSE

Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.

METHODS

Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.

RESULTS

Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.

Prevention of deep venous thrombosis and pulmonary embolism following stroke: a systematic review of published articles

We performed a systematic review of the literature on venous thromboembolism (VTE) prophylaxis following cerebral infarct (CI) and haemorrhagic stroke. MEDLINE, Cochrane, LILACS and SciELO databases were scanned, and the Abstracts from Brazilian, American and European Neurology and Stroke Congresses were scrutinized for clinical trials. Moreover, the reference lists of articles and reviews were searched. A pooled analysis of two large studies with aspirin was made. Both unfractionated heparin and low molecular weight heparins/heparinoids (LMWH) are partially effective for VTE prophylaxis after CI, and should be routinely used in patients with motor deficit and reduced mobility and no contraindications. Reduction of deep venous thrombosis is better established than the effect over pulmonary embolism or mortality. Some evidence points to a greater efficacy of LMWH. The available evidence does not support the use of mechanical methods or dextran. Aspirin may have a mild protective effect. Low-dose Warfarin might be useful in the rehabilitation setting. Strict recommendations cannot be made in patients with haemorrhagic stroke but intermittent pneumatic compression merits further study. There are important limitations of current VTE preventive strategies following stroke. Additional studies on the combination of methods after CI and of low doses of anticoagulants following cerebral haemorrhage are urgently needed.

Efficacy and Safety of Anticoagulant Treatment in Acute Cardioembolic Stroke

Background and Purpose— The role of anticoagulant treatment for acute cardioembolic stroke is uncertain. We performed an updated meta-analysis of all randomized trials to obtain the best estimates of the efficacy and safety of anticoagulants for the initial treatment of acute cardioembolic stroke.

Methods— Using electronic and manual searches of the literature, we identified randomized trials comparing anticoagulants (unfractionated heparin or low-molecular-weight heparin or heparinoids), started within 48 hours, with other treatments (aspirin or placebo) in patients with acute ischemic cardioembolic stroke. Two reviewers independently selected studies and extracted data on study design, quality, and clinical outcomes, including death or disability, all strokes, recurrent ischemic stroke, and cerebral symptomatic bleeding. Odds ratios for individual outcomes were calculated for each trial and data from all the trials were pooled using the Mantel-Haenszel method.

Results— Seven trials, involving 4624 patients with acute cardioembolic stroke, met the criteria for inclusion. Compared with other treatments, anticoagulants were associated with a nonsignificant reduction in recurrent ischemic stroke within 7 to 14 days (3.0% versus 4.9%, odds ratio 0.68, 95% CI: 0.44 to 1.06, P =0.09, number needed to treat=53), a significant increase in symptomatic intracranial bleeding (2.5% versus 0.7%, odds ratio 2.89; 95% CI: 1.19 to 7.01, P =0.02, number needed to harm=55), and a similar rate of death or disability at final follow up (73.5% versus 73.8%, odds ratio 1.01; 95% CI: 0.82 to 1.24, P =0.9).

Conclusions— Our findings indicate that in patients with acute cardioembolic stroke, early anticoagulation is associated with a nonsignificant reduction in recurrence of ischemic stroke, no substantial reduction in death and disability, and an increased intracranial bleeding.

What is the optimal pharmacological prophylaxis for the prevention of deep-vein thrombosis and pulmonary embolism in patients with acute ischemic stroke?

BACKGROUND

Pulmonary embolism after acute ischemic stroke (AIS) is associated with a high in-hospital mortality. The benefit from pharmacological prophylaxis for venous thromboembolism (VTE) is uncertain probably due to doubts about the optimal agent and dose. We evaluated the benefit/risk ratio of different anticoagulant regimens in the prevention of VTE in patients with AIS.

METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were searched up to January 2005. Randomized controlled trials (RCT) comparing early administration of either low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) with control were included. Endpoints were objectively diagnosed deep-vein thrombosis (DVT), pulmonary embolism, intracranial hemorrhage (ICH), and extracranial hemorrhage (ECH). Low-dose UFH was arbitrarily defined as < or =15,000 IU/day, low-dose LMWH as < or =6000 IU/day or weight-adjusted dose of < or =86 IU/kg/day.

RESULTS

Sixteen trials involving 23,043 patients with AIS met the inclusion criteria. The number of events was small and different doses of anticoagulant treatment were used. Compared to control, high-dose UFH was associated with a reduction in pulmonary embolism (OR=0.49, 95% confidence interval (CI)=0.29-0.83), but also with an increased risk of ICH (OR=3.86, 95% CI=2.41-6.19) and ECH (OR=4.74, 95% CI=2.88-7.78). Low-dose UFH decreased the thrombosis risk (OR=0.17, 95% CI=0.11-0.26), but had no influence on pulmonary embolism (OR=0.83, 95% CI=0.53-1.31); the risk of ICH or ECH was not statistically significant increased (OR=1.67, 95% CI=0.97-2.87 for ICH; and OR=1.58, 95% CI=0.89-2.81 for ECH, respectively). High-dose LMWH decreased both DVT (OR=0.07, 95% CI=0.02-0.29) and pulmonary embolism (0.44, 95% CI=0.18-1.11), but this benefit was offset by an increased risk for ICH (OR=2.01, 95% CI=1.02-3.96) and ECH (OR=1.78, 95% CI=0.99-3.17). Low-dose LMWH reduced the incidence of both DVT (OR=0.34, 95% CI=0.19-0.59) and pulmonary embolism (OR=0.36, 95% CI=0.15-0.87), without an increased risk of ICH (OR=1.39, 95% CI=0.53-3.67) or ECH (OR=1.44, 95% CI=0.13-16). For low-dose LMWH, the numbers needed to treat were 7 and 38 for DVT and pulmonary embolism, respectively.

CONCLUSIONS

Indirect comparison of low and high doses of UFH and LMWH suggests that low-dose LMWH have the best benefit/risk ratio in patients with acute ischemic stroke by decreasing the risk of both DVT and pulmonary embolism, without a clear increase in ICH or ECH.

Venous thromboembolism in patients with ischemic and hemorrhagic stroke

The rates of pulmonary embolism (PE), deep venous thrombosis (DVT), and their combination, venous thromboembolism (VTE), in hospitalized patients with stroke from 1979 to 2003 were determined from the National Hospital Discharge Survey. Of 14,109,000 patients hospitalized with ischemic stroke, PE occurred in 72,000 (0.51%), DVT in 104,000 (0.74%), and VTE in 165,000 (1.17%). Of 1,606,000 patients hospitalized with hemorrhagic stroke, rates were higher: PE occurred in 11,000 (0.68%), DVT in 22,000 (1.37%), and VTE in 31,000 (1.93%). The rates of VTE with ischemic stroke and with hemorrhagic stroke did not change over the 25-year period of observation.

Prevention of venous thromboembolism after acute ischemic stroke

Venous thromboembolism (VTE) is a common complication after acute ischemic stroke. When screened by 125I fibrinogen scanning or venography, the incidence of deep-vein thrombosis (DVT) in stroke patients is comparable with that seen in patients undergoing hip or knee replacement. Most stroke patients have multiple risk factors for VTE, like advanced age, low Barthel Index severity score or hemiplegia. As pulmonary embolism is a major cause of death after acute stroke, the prevention of this complication is of crucial importance. Prospective trials have shown that both unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are effective in reducing DVT and pulmonary embolism in stroke patients. Current guidelines recommend the use of these agents in stroke patients with risk factors for VTE. Some clinicians are concerned that the rate of intracranial bleeding associated with thromboprophylaxis may outweigh the benefit of prevention of VTE. Low-dose LMWH and UFH seem, however, safe in stroke patients. Higher doses clearly increase the risk of cerebral bleeding and should be avoided for prophylactic use. Both aspirin and mechanical prophylaxis are suboptimal to prevent VTE. Graduated compression stockings should be reserved to patients with a clear contraindication to antithrombotic agents.

Enoxaparin Versus Unfractionated Heparin in the Prevention of Venous Thromboembolism After Acute Ischemic Stroke: Rationale, Design, and Methods of an Open-Label, Randomized, Parallel-Group Multicenter Trial

BACKGROUND

Small sample size and methodologic limitations make it difficult to interpret and compare trials of low molecular-weight heparin (for example, enoxaparin) versus unfractionated heparin as prophylactic treatment for venous thromboembolism (VTE), that is, deep vein thrombosis and/or pulmonary embolism, in patients with acute ischemic stroke. This prospective, open-label, randomized, parallel-group, multicenter trial is designed to evaluate the efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of VTE after acute ischemic stroke.

METHODS

Approximately 1760 patients with the diagnosis of acute ischemic stroke accompanied by leg paralysis will be randomly assigned (1:1) within 48 hours of stroke symptoms to receive enoxaparin (40 mg subcutaneously) once daily or unfractionated heparin (5000 U subcutaneously) every 12 hours for 10 +/- 4 days. Contrast venography will be used to evaluate asymptomatic patients after treatment for deep vein thrombosis. In addition, diagnostic algorithms will be used to objectively confirm or rule out VTE events for patients in whom upper- or lower-extremity deep vein thrombosis/pulmonary embolism is suggested.

RESULTS

The primary efficacy end point measure will be the cumulative occurrence of documented VTE during the initial treatment period. Secondary end points are VTE incidence; neurologic outcome at days 30, 60, and 90; safety; and health care resource use during initial hospitalization and during the 30- and 90-day follow-up periods.

CONCLUSIONS

This study will provide clinical and health economic data regarding the use of enoxaparin as primary prophylactic treatment of VTE in patients who have had an acute ischemic stroke.

Other supportive therapies in sepsis: an evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for other supportive therapies in sepsis that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Patients with severe sepsis should be treated with deep-vein thrombosis prophylaxis. Low-dose unfractionated heparin or low molecular weight heparin is preferred. Use of graduated compression devices is recommended in septic patients with contraindication to the use of heparin or combined with heparin in very high-risk patients. Stress ulcer prophylaxis should be given to all patients with severe sepsis. Histamine-2 receptor antagonists are more effective than sucralfate in decreasing bleeding risk and transfusion requirements. Proton pump inhibitors have not been assessed in a direct comparison with histamine-2 receptor antagonists but do demonstrate equivalency and ability to increase gastric pH.

Deep vein thrombosis and pulmonary embolism in an ambulatory chronic stroke patient

PURPOSE

Deep vein thrombosis (DVT) is a well-known complication of stroke and frequently develops in acute stroke patients. Immobility in stroke patients increases the risk of DVT and pulmonary embolism (PE). The incidence of DVT in non-ambulatory stroke patients is more frequent than the incidence in ambulatory stroke patients. We report a case of DVT and PE in an ambulatory chronic stroke patient.

METHOD

Initial physical examination showed heat and swelling of hemiplegic leg. The patient was only able to ambulate with the assist of a monocane and a plastic leaf spring orthosis due to ankle dorsiflexor weakness. The patient was treated with anticoagulation and inferior vena cava filter placement.

RESULTS

After long-term anticoagulation, follow-up studies revealed satisfactory resolution of DVT and PE.

CONCLUSIONS

We present a case of DVT and PE which developed during the chronic stage of stroke, 2 years from the onset of stroke, and review the cause of DVT.

Validation of a clinical guideline on prevention of venous thromboembolism in medical inpatients: a before-and-after study with systematic ultrasound examination

BACKGROUND

Clinical practice guidelines on prevention of venous thromboembolism in medical inpatients have been implemented in various settings, although few studies have assessed their impact on venous thromboembolism events.

OBJECTIVE

To determine whether the implementation of a locally developed guideline is followed by changes in the rate of deep vein thrombosis.

DESIGN

A before-and-after study consisting in two "1-day" cross-sectional studies.

SETTING

Thirteen adult medical wards in a teaching hospital in France.

SUBJECTS

All the patients hospitalized on the day of the cross-sectional study.

INTERVENTION

A clinical guideline integrating scientific evidence and data on target medical providers' practices was developed by a local expert panel and implemented through a multifaceted intervention.

MEASUREMENTS

Prevalence of deep vein thrombosis detected by systematic ultrasound examination.

RESULTS

The study included 338 patients in the preintervention sample and 340 in the postintervention sample. The prevalence of deep vein thrombosis decreased from 9.5% (95% CI, 6.6-13.1) in the preintervention sample to 3.2% (95% CI, 1.6-5.7) in the postintervention sample (P < 0.01). The decrease in the rate of thrombosis involved all deep veins of the lower limbs and remained significant after adjustment for risk factors (adjusted odds ratio = 0.47, 95% CI, 0.32-0.70). No additional cases of pulmonary embolism or deep vein thrombosis were reported either on the day of the study or in the following 2 days.

CONCLUSIONS

Active implementation of a clinical practice guideline directed at medical providers (doctors, nurses and physical therapists) can be followed by a significant decrease in prevalence of deep vein thrombosis.

The effectiveness of anticoagulant and antiplatelet agents in preventing venous thromboembolism during stroke rehabilitation: a historical cohort study

OBJECTIVE

To determine the effectiveness of anticoagulant and antiplatelet agents in preventing venous thromboembolism (VTE) during stroke rehabilitation.

DESIGN

Historical cohort study.

SETTING

Acute inpatient rehabilitation hospital.

PARTICIPANTS

Consecutive patients (N=1506) with ischemic and hemorrhagic stroke admitted for rehabilitation.

INTERVENTIONS

Documented use of anticoagulants (warfarin or anticoagulant doses of heparin), heparin in prophylactic doses, and antiplatelet agents.

MAIN OUTCOME MEASURE

Occurrence of deep vein thrombosis detected by ultrasound or venography or pulmonary embolism detected by ventilation perfusion scan, spiral computed tomography, or pulmonary angiography.

RESULTS

Fifty-eight VTE events occurred (3.9% incidence or 1.36 events per 1000 patient days), with higher risk in patients with severe stroke. Only therapeutic anticoagulation had a statistically significant protective effect for VTE risk in univariate analysis (odds ratio [OR]=.44; 95% confidence interval [CI],.20-.98). After adjusting for multiple medication use and other factors, including age, stroke onset to admission interval, length of rehabilitation stay, cause of stroke, and admission National Institutes of Health Stroke Scale score, therapeutic anticoagulation gave strong protection against VTE (OR=.37; 95% CI,.15-.88), followed by heparin (OR=.48; 95% CI,.23-.98) but not by antiplatelet agents (OR=.79; 95% CI,.40-1.57). No medications were associated with significant bleeding complications.

CONCLUSIONS

Use of therapeutic anticoagulants or prophylactic heparin prevented VTE in stroke patients during inpatient rehabilitation.

Anticoagulants for acute ischaemic stroke

BACKGROUND

Most ischaemic strokes are caused by blood clots blocking an artery in the brain. Clot prevention with anticoagulant therapy could have a significant impact on patient survival, disability and stroke recurrence.

OBJECTIVES

The objective of this review was to assess the effect of anticoagulant therapy versus control in the early treatment of patients with acute ischaemic stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group trials register (last searched 30 October 2003). For previous updates of this review, we searched the register of the Antithrombotic Trialists' (ATT) Collaboration, consulted MedStrategy (1995), and contacted relevant drug companies.

SELECTION CRITERIA

Randomised trials comparing early anticoagulant therapy (started within two weeks of stroke onset) with control in patients with acute presumed or confirmed ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data.

MAIN RESULTS

Twenty-two trials involving 23,547 patients were included. The quality of the trials varied considerably. The anticoagulants tested were standard unfractionated heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants, and thrombin inhibitors. Based on nine trials (22,570 patients) there was no evidence that anticoagulant therapy reduced the odds of death from all causes (odds ratio (OR) = 1.05, 95% confidence interval (CI) 0.98 to 1.12) at the end of follow-up. Similarly, based on six trials (21,966 patients), there was no evidence that anticoagulants reduced the odds of being dead or dependent at the end of follow-up (OR = 0.99; 95% CI 0.93 to 1.04). Although anticoagulant therapy was associated with about 9 fewer recurrent ischaemic strokes per 1000 patients treated (OR = 0.76; 95% CI 0.65 to 0.88), it was also associated with a similar sized 9 per 1000 increase in symptomatic intracranial haemorrhages (OR = 2.52; 95% CI 1.92 to 3.30). Similarly, anticoagulants avoided about 4 pulmonary emboli per 1000 (OR = 0.60, 95% CI 0.44 to 0.81), but this benefit was offset by an extra 9 major extracranial haemorrhages per 1000 (OR = 2.99; 95% CI 2.24 to 3.99). Sensitivity analyses did not identify a particular type of anticoagulant regimen or patient characteristic associated with net benefit.

REVIEWERS' CONCLUSIONS

Immediate anticoagulant therapy in patients with acute ischaemic stroke is not associated with net short- or long-term benefit. The data from this review do not support the routine use of any type of anticoagulant in acute ischaemic stroke. People treated with anticoagulants had less chance of developing deep vein thrombosis (DVT) and pulmonary embolism (PE) following their stroke, but these sorts of blood clots are not very common, and may be prevented in other ways.

Prophylactic Anticoagulation for Venous Thromboembolic Disease in Geriatric Patients

Venous thromboembolic disease (VTED) occurs commonly in geriatric medical patients, causing significant morbidity and mortality. Although VTED is preventable, prophylactic anticoagulation is underused. Awareness of the clinical risk factors that contribute to VTED in the elderly is essential for identifying candidates for prophylaxis. Iatrogenic risk factors include venous catheterization, transvenous pacemaker placement, hormone replacement therapy, and immobilization or prolonged bed rest. Medical conditions associated with increased risk include a previous episode of VTED, myocardial infarction, heart failure, severe lung disease, cancer, and neurological conditions associated with paresis. Obstacles to the widespread usage of VTED prophylaxis in geriatric medical patients include the clinically silent nature of VTED, underestimation of the risk and clinical effect of VTED in this population, and concerns about the cost and safety of anticoagulant therapy in this population. Clinical practice guidelines devised specifically for geriatric medical patients facilitate rational use of thromboprophylaxis in this population. The safety, efficacy, cost-effectiveness, and convenience of low-molecular-weight heparins for thromboprophylaxis are reflected in their increasing prominence in clinical practice guidelines and clinical use.

Prevention of venous thromboembolism in acute medical illness

Each year millions of patients experience a venous thromboembolic event. Due to the significant morbidity and mortality associated with venous thromboembolism (VTE), prevention is critical. Several groups, such as those undergoing orthopedic or general surgery, and patients experiencing acute myocardial infarction, are known to be at high risk for VTE. General medical patients-the medically ill-are also at risk, but they receive insufficient prophylaxis, which may be due to underestimation or lack of assessment of their risk. The American College of Chest Physicians recommends either unfractionated heparin or low-molecular-weight heparin to prevent VTE in these patients. The different pharmacologic profiles and dosing methods of these two groups of agents suggest that efficacy and safety may not be equivalent. Due to heterogeneity of medically ill patients and variability in clinical trials, a detailed review of the literature was performed to assist clinicians in assessing risk and choice of a regimen to prevent VTE.