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(Stroke. 2001;32:577.)
© 2001 American Heart Association, Inc.

Comments, Opinions, and Reviews

Immediate Anticoagulation in Acute Focal Brain Ischemia Revisited

Gathering the Evidence

Ángel Chamorro, MD

From the Neurology Service and Institut d’Investigació Biomedica August Pi i Sunyer (IDIBAPS) Hospital Clinic, Barcelona, Spain.

Correspondence to Angel Chamorro, MD, Neurology Service, Hospital Clinic, 170 Villarroel, 08036 Barcelona, Spain. E-mail chamorro@medicina.ub.es

Key Words: cerebrovascular disorders • heparin • inflammation

	"Immediate" Heparin Anticoagulation in Acute Ischemic Stroke: Gathering the Evidence

 
Several large randomized clinical trials (RCTs) have recently evaluated the efficacy and safety of "immediate" administration of low-fixed-dose subcutaneous unfractionated heparin (UFH), medium-fixed-dose subcutaneous UFH, dalteparin, nadroparin, certoparin, tinzaparin, or danaparoid in patients with presumed acute ischemic stroke. A systematic review of 23 427 patients anticoagulated within 2 weeks from the onset of symptoms disclosed that treatment was associated with about 9 fewer recurrent ischemic strokes per 1000 patients treated, but it was also associated with a similar sized 9 per 1000 increase in symptomatic intracranial hemorrhages.¹ Disclaiming theoretical biological disadvantages of UFH, the highest bleeding rate was found in patients treated with low-molecular-weight heparin (LMWH) or heparinoids. Nevertheless, some clinical guidelines recommend immediate anticoagulation for patients at higher risk of stroke recurrence, whereas delaying anticoagulation for several days is preferred for patients at low risk for early recurrence.² Case-by-case consideration of anticoagulation is advocated by others, depending on the underlying vascular mechanism, the size and location of the affected vessel, and extent of the atherosclerotic process. Finally, the Cochrane Investigators disregard any type of anticoagulant in acute ischemic stroke.¹

The evidence favoring or discouraging the administration of adjusted-dose UFH to patients with ischemic stroke is scanty.^{3 4 5} Available data on "immediate" anticoagulation is also inadequate, especially if we concur that a 2-week delay outlasts the concept of treatment immediacy in ischemic stroke. Clashing with the main conclusion of the systematic review, a few studies emphasized the relevance of dose-adjusted UFH⁶ and treatment expeditiousness.⁷ Thus, recovery was greater in patients treated . . . [Full Text of this Article]

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