Published online before print October 21, 2004, doi: 10.1161/01.STR.0000147720.27350.09
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(Stroke. 2004;35:2911.)
© 2004 American Heart Association, Inc.
Controversies in Stroke |
Effective Prophylaxis for Deep Vein Thrombosis After Stroke
Low-Dose Anticoagulation Rather Than Stockings Alone: For
From the Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City.
Correspondence to Dr Harold P. Adams, Jr, Department of Neurology, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242. E-mail harold-adams{at}uiowa.edu
Key Words: deep vein thrombosis • heparin • pulmonary embolism • stroke
Deep vein thrombosis (DVT) is an important cause of morbidity in its own right and it is complicated by pulmonary embolism, a potential cause of death after stroke.1 DVT occurs most commonly among seriously ill or elderly patients who have paralysis of the lower extremity, and it can develop in either an acute care or a rehabilitation setting.2 Because DVT can be prevented effectively, treatment guidelines rightly emphasize the importance of prophylactic measures.3
Treatment options include early ambulation, use of stockings supplemented by alternating pressure devices, and antithrombotic agents. Each option has limitations. Whereas early mobilization is recommended for mildly affected patients, seriously ill patients or those with severe motor impairments often cannot return to walking. Stockings can be used to treat bedridden patients who have an intracranial hemorrhage or another contraindication for antithrombotic agents, but data showing efficacy in the setting of stroke are limited. Any recommendation is inferred from the experience in other groups of patients.2,4 In addition, these interventions cannot be used on a long-term basis, and patients initially treated with compression stockings subsequently often need antithrombotic therapy.
Oral anticoagulants are the standard intervention for the long-term prevention of DVT, and they are effective in patients surviving stroke.5,6 Anticoagulants are the preferred therapy for patients considered to be at high risk for DVT. Their status is demonstrated by the design of clinical trials of other interventions; their usefulness is compared with the effectiveness of anticoagulation. Evidence for the efficacy of parenteral anticoagulants in preventing DVT, in a variety of settings, including for treatment of immobilized patients, is robust.5 Data from individual trials and meta-analyses demonstrate the efficacy of anticoagulants in preventing DVT after stroke.7–10 However, Kelly et al2 rightly note that the significance of the meta-analyses is muted by the heterogenous nature of the included trials. Hillbom et al11 showed that low molecular weight heparin probably was superior to unfractionated heparin in preventing venous thromboembolic events following ischemic stroke.
Whereas anticoagulants are effective in preventing DVT after stroke, the real question is whether these medications can be administered with a reasonable degree of safety. Their safety partially relates to the timing of initiation of treatment. Even low-dose anticoagulants given to prevent DVT can be accompanied by bleeding. The issue is whether the risk of bleeding, including intracranial hemorrhage, outweighs the benefit of DVT prophylaxis. Presumably, patients with a primary intracranial hemorrhage or a large multilobar infarction might not tolerate early anticoagulation to prevent DVT. Still, the bleeding risk of parenterally administered anticoagulants used to prevent DVT is not known. For example, one small trial found that heparin could be started safely within 2 days of a spontaneous intracerebral hemorrhage.12 Most of the available information about the use of anticoagulants after ischemic stroke is inferred from clinical trials in which the primary indication for emergent anticoagulation was to improve neurological outcome.8
Using care, anticoagulants can be recommended for the reduction of the risk for DVT in many patients with recent stroke. Evidence to support their use is the stronger than that for either stockings or antiplatelet agents. Some patients probably can be safely treated within a few hours of stroke. Besides being effective, anticoagulant prophylaxis eliminates the necessity for the compression stockings and devices, which are cumbersome and often not tolerated well by patients. Anticoagulants remain a key component of ancillary care of patients with stroke. In carefully selected patients, these medications remain the best therapy to prevent DVT. The duration of treatment will depend on the needs of the patient and the perceived long-term risk of the medications. Maybe future studies will demonstrate that compression stockings or devices or antiplatelet agents are equal to or superior to anticoagulants. Until then, these measures should be reserved for treatment of those patients who might have a high bleeding risk associated with anticoagulation.
Received July 19, 2004; accepted July 19, 2004.
References
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3. Adams HP, Adams RJ, Brott T, del Zoppo GJ, Furlan A, Goldstein LB, Grubb RL, Higashida R, Kidwell C, Kwiatkowski TG, Marler JR, Hademenos GJ; Stroke Council of the American Stroke Association. Guidelines for the early management of patients with ischemic stroke. A scientific statement from the Stroke Council of the American Stroke Association. Stroke. 2003; 34: 1056–1083.
4. Mazzone C, Chiodo Grandi F, Sandercock P, Miccio M, Salvi R. Physical methods for preventing deep vein thrombosis in stroke. Cochrane Database of Systematic Reviews. 2003: 3.
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7. Sandercock PA, van den Belt AG, Lindley RI, Slattery J. Antithrombotic therapy in acute ischaemic stroke: an overview of the completed randomised trials. J Neurol Neurosurg Psychiatry. 1993; 56: 17–25.
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9. Coull BM, Williams LS, Goldstein LB, Meschia JF, Heitzman D, Chaturvedi S, Johnston KC, Starkman S, Morgenstern LB, Wilterdink JL, Levine SR, Saver JL; American Academy of Neurology; American Stroke Association. Anticoagulants and antiplatelet agents in acute ischemic stroke. Report of the Joint Stroke Guideline Development Committee of the Am Academy of Neurology and the Am Stroke Association (a division of the Am Heart Association). Neurology. 2002; 59: 13–22.
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