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Anticoagulation in acute ischaemic stroke: deep vein thrombosis prevention and long-term stroke outcomes
1Centre for Vascular Medicine, University of Amsterdam, The Netherlands. a.w.lensing@amc.uva.nl
Insights
Low-molecular-weight heparins (LMWHs) and heparinoids show promise in reducing venous thromboembolism (VTE) after acute stroke. While evidence for improved long-term outcomes is conflicting, these agents may offer a better safety profile than unfractionated heparin (UFH).
Area of Science:
- Neurology
- Cardiology
- Hematology
Background:
- Ischemic stroke is a leading cause of death and disability globally, with limited acute treatment options.
- Current stroke prevention strategies include antiplatelet agents and carotid endarterectomy.
- Venous thromboembolism (VTE) is a significant secondary complication following stroke.
Purpose of the Study:
- To evaluate the role of antithrombotic therapy in acute stroke management.
- To compare the efficacy and safety of low-molecular-weight heparins (LMWHs) and heparinoids against unfractionated heparin (UFH).
- To assess the potential dual benefit of antithrombotic agents in preventing cerebral thrombosis and secondary VTE.
Main Methods:
- Review of recent clinical trials investigating LMWHs and heparinoids in acute stroke patients.
- Analysis of data on the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE).
- Examination of evidence regarding long-term outcomes, including death and residual disability.
Main Results:
- Recent trials indicate LMWHs and heparinoids significantly reduce DVT and PE in stroke patients.
- Some studies suggest improved long-term outcomes (death and disability) with these agents.
- Conflicting data exists across different studies regarding the overall benefit.
Conclusions:
- LMWHs and heparinoids may offer an improved antithrombotic-to-hemorrhagic effect ratio compared to UFH.
- The precise role of LMWHs and heparinoids in acute ischemic stroke treatment requires further clarification.
- Further research is needed to reconcile conflicting data and establish optimal therapeutic strategies.
Abstract:
Ischaemic stroke accounts for 70-85% of stroke incidence worldwide, causing substantial morbidity and mortality. Antiplatelet agents and carotid endarterectomy are effective in stroke prevention but active therapy for acute stroke is limited at present. Treatments investigated to date include thrombolysis and antiplatelet agents, both of which have been shown to modify the effects of stroke and provide a small long-term benefit in selected patients, and anticoagulation with heparin derivatives and oral agents. The value of unfractionated heparin (UFH) in modifying the acute effects of stroke has never been clearly established, and the risk of intracranial bleeding has limited its clinical application. However, disability and death following stroke stem from both the acute cerebral event and the secondary development of venous thromboembolism (VTE). Antithrombotic therapy may therefore, in principle, provide the dual benefit of retarding ongoing cerebral thrombosis and preventing secondary VTE. Low-molecular-weight heparins (LMWHs) and one heparinoid may have an improved ratio of antithrombotic action to haemorrhagic effect compared with UFH. Recent trials with these agents demonstrated a significant reduction in deep vein thrombosis and pulmonary embolism. Evidence has also emerged of improved long-term outcomes in terms of combined rates of death and residual disability, but data from different studies are conflicting. The potential role of LMWHs and heparinoids in acute stroke remains to be clarified.