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Anticoagulants for acute ischaemic stroke
G Gubitz1, C Counsell, P Sandercock
1Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU. pags@skull.dcn.ed.ac.uk
Insights
Early anticoagulant therapy for acute ischaemic stroke does not show net benefits. This review found no evidence to support routine use of anticoagulants in acute stroke patients.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Clinical Trials
Background:
- Ischaemic stroke is primarily caused by cerebral artery blockages from blood clots.
- Anticoagulant therapy is a potential strategy for preventing clot formation, impacting patient survival and reducing disability.
Purpose of the Study:
- To evaluate the efficacy of early anticoagulant therapy in managing acute ischaemic stroke patients.
Main Methods:
- Systematic review of randomized controlled trials comparing early anticoagulant therapy (initiated within two weeks of stroke onset) with control groups.
- Searched Cochrane Stroke Group trials register and MedStrategy, also contacted pharmaceutical companies.
- Data extraction and quality assessment performed independently by two reviewers.
Main Results:
- Twenty-one trials with 23,427 patients were analyzed, showing variable quality.
- No significant reduction in all-cause mortality (OR 1.05) or death/dependency (OR 0.99) was observed with anticoagulant therapy.
- While anticoagulants reduced recurrent strokes and pulmonary emboli, they increased symptomatic intracranial and major extracranial haemorrhages, resulting in no net benefit.
Conclusions:
- Early anticoagulant therapy in acute ischaemic stroke offers no discernible short- or long-term net benefit.
- Current evidence does not support the routine administration of any anticoagulant type 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 recurrence of stroke.
Objectives:
The objective of this review was to assess the effect of anticoagulant therapy in the early treatment of patients with acute ischaemic stroke.
Search Strategy:
We searched the Cochrane Stroke Group trials register (most recent search: March 1999) and consulted MedStrategy (1995). We also contacted 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-one trials involving 23,427 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 eight trials (22,450 patients) there was no evidence that anticoagulant therapy reduced the odds of death from all causes (odds ratio 1.05, 95% confidence intervals 0.98-1.12). Similarly, based on five trials (21, 846 patients), there was no evidence that anticoagulants reduced the odds of being dead or dependent at the end of follow-up (odds ratio 0.99, 95% confidence intervals 0.94-1.05). Although anticoagulant therapy was associated with about 9 fewer recurrent ischaemic strokes per 1000 patients treated, it was also associated with a similar sized 9 per 1000 increase in symptomatic intracranial haemorrhages. Similarly, anticoagulants avoided about 4 pulmonary emboli per 1000, but this benefit was offset by an extra 9 major extracranial haemorrhages per 1000. Sensitivity analyses did not identify a particular type of anticoagulant regimen or patient characteristic associated with net benefit.
Reviewer'S 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.