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(Stroke. 2002;33:659.)
© 2002 American Heart Association, Inc.

Editorials

Do We Really Need a Better Way to Give Heparin in Acute Cerebral Ischemia?

Robert G. Hart, MD J. Donald Easton, MD

From the Department of Medicine/Neurology (R.G.H.), University of Texas, San Antonio, and the Department of Neurology (D.E.), Brown University, Providence, RI.

Correspondence to Dr. Robert G. Hart, Department of Medicine (Neurology), University of Texas HSC, 7703 Floyd Curl Dr, San Antonio, TX 78229-3900. E-mail HartR@uthscsa.edu

Key Words: cerebral ischemia • heparin • stroke, acute

In the early 1980s, we assiduously followed management guidelines advocating intravenous heparin for patients within 2 months of transient ischemic attack (TIA) and for most patients with acute ischemic stroke. Heparin flowed freely; there were always 2 to 3 patients receiving it on the neurology ward and a dozen partial thromboplastin times were urgently checked each day. Times have changed. High standards of evidence are expected to support management recommendations, grounded firmly in randomized clinical trials rather than traditional GOBSAT methods (Good Old Boys Sat At Table).¹ Nine randomized trials have tested intravenous unfractionated heparin or related agents in acute stroke.² Critical analysis of the accumulated evidence does "not support the routine use of any type of anticoagulant in acute ischemic stroke."² It is clear that intravenous heparin or related low-molecular-weight heparins do not benefit most patients with acute stroke caused by common cerebrovascular disorders. Of note, the mean interval from stroke onset to initiation of heparin averages about 20 hours in existing clinical trials.

Is the randomized trial reported in this issue of Stroke³ comparing two different methods to achieve therapeutic levels of anticoagulation with intravenous heparin much ado about nothing, 20 years too late? No. There is solid evidence favoring intravenous heparin use for acute cerebral venous thrombosis.⁴ In our view, shared by many other stroke experts,⁵ selected acute stroke patients with cerebral arterial dissection, with aseptic embolism from prosthetic cardiac valves, or with prothrombotic disorders likely benefit from intravenous heparin, although based on empiric evidence (as yet . . . [Full Text of this Article]

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