What is the recommended Deep Vein Thrombosis (DVT) prophylaxis in patients with stroke?

From the Guidelines

For immobile stroke patients without contraindications, intermittent pneumatic compression (IPC) in addition to routine care is recommended to reduce the risk of deep vein thrombosis (DVT). This recommendation is based on the 2018 guidelines for the early management of patients with acute ischemic stroke from the American Heart Association/American Stroke Association 1. The guidelines suggest that IPC, in addition to routine care such as aspirin and hydration, is more effective than routine care alone in reducing the risk of DVT.

Key points to consider in DVT prophylaxis for stroke patients include:

• The use of IPC devices, which should be applied as soon as possible and continued until the patient becomes independently mobile or is discharged from the hospital 1.
• The assessment of skin integrity daily for patients wearing IPC devices, with consultation from a wound care specialist if skin breakdown occurs 1.
• The consideration of pharmacological VTE prophylaxis, such as low-molecular-weight heparin, for patients at high risk of VTE, provided there are no contraindications such as hemorrhagic stroke or active bleeding 1.
• Early mobilization, which is effective in preventing VTE and should be encouraged for all stroke patients when medically stable 1.

It's essential to individualize DVT prophylaxis based on the patient's specific risk factors, type of stroke, and bleeding risk. The benefit of preventing potentially fatal pulmonary embolism outweighs the small risk of bleeding complications in most patients. Therefore, a comprehensive approach to DVT prophylaxis, including IPC, pharmacological prophylaxis, and early mobilization, should be implemented to reduce the risk of VTE in stroke patients.

From the Research

DVT Prophylaxis in Stroke

• The risk of deep vein thrombosis (DVT) after stroke is increased in patients with restricted mobility, a previous history of DVT, dehydration, or comorbidities such as malignant diseases or clotting disorders 2.
• Patients with an increased risk of DVT should receive prophylactic treatment, which may include mobilization as soon as possible, keeping the patient well hydrated, and treatment with subcutaneously administered low-dose unfractionated heparin or low-molecular-weight heparin 2, 3.
• Anti-embolism stockings are not recommended for preventing DVT or pulmonary embolism in patients with stroke, as they have been shown to be ineffective and are associated with a significantly increased risk of skin breaks 2.
• The use of intermittent pneumatic compression is currently under study, but its effectiveness in preventing DVT in stroke patients is not yet established 2.
• Low-molecular-weight heparins, such as enoxaparin, have been shown to be effective in reducing the risk of venous thromboembolism in patients with acute ischemic stroke, and may be preferred over unfractionated heparin due to their better clinical benefits to risk ratio and convenience of once daily administration 3, 4.

Mobilization and Functional Outcomes

• Early mobilization, defined as out-of-bed activities in the acute stroke phase, has been shown to improve functional capacity and reduce complications after stroke 5.
• The optimal time to start early mobilization is more than 24 hours after stroke, according to hemodynamic stability and safety criteria, and the duration of mobilization is recommended to be between 15 and 45 minutes, divided into one, two, or three times a day 5.
• Interventions such as cardiorespiratory training, therapeutic exercise, task-oriented training, constraint-induced movement therapy, mental practice, and mirror therapy have been shown to possess credible evidence to improve functional movement of persons with stroke 6.
• Neuromuscular electrical stimulation shows promise as an intervention for stroke survivors, but further research is needed to determine its optimal timing and dosage 6.