Retrospective study of Heparin Administration for Ischemic Stroke when there is an IV-tPA Contraindication

The majority of patients presenting with an ischemic stroke arrive after the 3-4.5 h time window allowed for intravenous tissue plasminogen activator (IV tPA) administration. Most of the literature on heparin use in acute ischemic stroke does not describe dose-adjusted intravenous unfractionated heparin (IV UFH) without bolus, a common method of administration. This study was designed to test whether an anticoagulation regimen of intravenous dose-adjusted UFH with no bolus, in patients with a contraindication to IV TPA, administered within 24 h of an acute ischemic stroke could be effective and safe.

We conducted a retrospective study of 273 patients over two consecutive years with acute ischemic stroke, who were outside the window for IV tPA. All patients had imaging studies on admission. The primary outcome measure of the study was to evaluate the safety of dose-adjusted IV UFH use in the setting of acute stroke. We looked at duration of heparin infusion, average partial thromboplastin time (PTT) value, and the incidence of new hemorrhagic events.

A total of 273 patients met the inclusion criteria. These patients received heparin infusion within 24 h of symptom onset. The duration of intravenous heparin infusion ranged from 1 to 18 days with a mean of 4 days. Mean PTT value was 72.4. Hemorrhagic complications occurred in 26 patients (9.5%), and included 12 asymptomatic petechial or hemorrhagic conversion (4.3%), 2 symptomatic intracranial hemorrhages (0.7%), 5 gastrointestinal bleeds (2 requiring transfusion and interventions), 2 patients experienced benign hematuria, 4 patients with groin hematomas, and one neck hematoma.

This study suggests that intravenous dose-adjusted UFH with no bolus can be administered to patients with acute ischemic stroke with relative safety.