Abstract 2394: What is the Optimal Pharmacological Prophylaxis for the Prevention of Deep-Vein Thrombosis and Pulmonary Embolism in Patients with Acute Ischemic Stroke?
Background: Pulmonary embolism (PE) after acute ischemic stroke (AIS) is associated with a high in-hospital mortality. The benefit from pharmacological prophylaxis for venous thrombo-embolism (VTE) is uncertain probably due to doubts about the optimal agent and dose. We evaluated the benfit/risk ratio of different anticoagulant regimens in the prevention of VTE in patients with AIS.
Methods: The MEDLINE, EMBASE, and Cochrane Library databases were searched up to january 2005. Randomized controlled trials comparing early administration of either low-molecular-weigh-heparin (LMWH) or unfractionated heparin (UFH) with control were included. Endpoints were objectively diagnosed deep-vein thrombosis (DVT), pulmonary embolism (PE), intracranial hemorrhage (ICH), or extracranial hemorrhage (ECH). Low-dose UFH was defined as <15.000 IU/day, low-dose LMWH as <6000 IU/day or <86 IU/kg/day.
Results: Sixteen trials involving 23.043 patients with AIS met the inclusion criteria. The number of events was small and different doses of anticoagulant treatment were used. Compared to control, high-dose UFH was associated with a reduction in PE (OR 0.49, 95%CI 0.29 – 0.83), but also with an increased risk of ICH (OR 3.86, 95%CI 2.41– 6.19) and ECH (OR 4.74, 95%CI 2.88 –7.78). Low-dose UFH decreased thrombosis risk (OR 0.17, 95%CI 0.11– 0.26), but had no influence on PE (OR 0.83, 95%CI 0.53–1.31), while the risk of bleeding was not increased. High-dose LMWH decreased the risk of both DVT and PE, but this benefit was offset by an two-fold increased risk for ICH and ECH. Low-dose LMWH reduced the incidence of both DVT (OR 0.34, 95%CI 0.19 – 0.59) and PE (OR 0.36, 95%CI 0.15– 0.87), without an increased risk of ICH or ECH. The number needed to treat were 7 and 38 for DVT and PE, respectively.
Conclusions: Low-dose LMWH seems to have the best benefit/risk ratio in patients with AIS by decreasing the risk of DVT and PE without a clear increase in ICH or ECH.