Is Lovenox (enoxaparin) indicated in acute ischemic stroke?

From the Guidelines

Lovenox (enoxaparin) should not be used as a primary treatment for acute ischemic stroke, but may be considered for prophylactic use in immobilized patients to prevent deep vein thrombosis 24-48 hours after stroke onset, as recommended by the Canadian Stroke Best Practice Recommendations [ 1 ]. The standard of care for eligible patients with acute ischemic stroke is intravenous tissue plasminogen activator (tPA) within 4.5 hours of symptom onset, possibly followed by mechanical thrombectomy in appropriate cases with large vessel occlusion. Some key points to consider when deciding on the use of Lovenox in acute ischemic stroke include:

• The pathophysiology of ischemic stroke, which involves arterial occlusion rather than venous thrombosis
• The increased risk of hemorrhagic transformation when anticoagulating acutely infarcted brain tissue
• The potential benefits of prophylactic anticoagulation in preventing deep vein thrombosis in immobilized patients
• The recommendations of relevant guidelines, such as the Canadian Stroke Best Practice Recommendations [ 1 ] and the American Heart Association/American Stroke Association guidelines [ 1 ] It is also important to note that full anticoagulation with Lovenox in acute ischemic stroke carries significant bleeding risk, especially in patients who have received thrombolytic therapy. However, the use of prophylactic-dose heparin or intermittent pneumatic compression devices is suggested for patients with acute stroke and restricted mobility [ 1 ]. In general, the decision to use Lovenox in acute ischemic stroke should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history. Some studies have compared the use of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) for the prevention of venous thromboembolism in patients with acute ischemic stroke, with some studies suggesting that LMWH may be more effective [ 1 ]. Overall, the use of Lovenox in acute ischemic stroke should be guided by the principles of evidence-based medicine and the recommendations of relevant guidelines.

From the Research

Administration of Lovenox in Acute Ischemic Stroke

• The use of anticoagulants, such as Lovenox (enoxaparin), in the management of acute ischemic stroke is a topic of ongoing debate 2, 3.
• Some studies suggest that anticoagulation may prevent recurrent cerebral infarction, but it also carries a risk of hemorrhagic transformation 2.
• A Cochrane review of 28 trials involving 24,025 participants found that early anticoagulation did not reduce the odds of death or dependence at the end of follow-up, but it was associated with fewer recurrent ischemic strokes and an increased risk of symptomatic intracranial hemorrhage 3.
• The review also found that early anticoagulation reduced the frequency of symptomatic pulmonary emboli, but this benefit was offset by an increase in extracranial hemorrhage 3.
• Other studies have focused on the use of thrombolytics, such as tenecteplase and alteplase, in the treatment of acute ischemic stroke, but do not provide direct evidence on the use of Lovenox 4, 5, 6.
• Overall, the current evidence does not support the routine use of anticoagulants, including Lovenox, for acute ischemic stroke 3.

Key Findings

• No net short- or long-term benefit of early anticoagulant therapy after acute ischemic stroke 3.
• Anticoagulants reduce recurrent stroke, deep vein thrombosis, and pulmonary embolism, but increase bleeding risk 3.
• The use of anticoagulants in acute ischemic stroke should be individualized and based on the specific clinical circumstances 2, 3.