From the Guidelines
For patients recently started on Plavix (clopidogrel) and aspirin for acute cerebrovascular accident (CVA), intermittent pneumatic compression (IPC) is recommended as the primary method of deep vein thrombosis (DVT) prophylaxis, due to its proven efficacy in reducing DVT risk without significantly increasing the risk of bleeding complications, as evidenced by the 2018 guidelines for the early management of patients with acute ischemic stroke 1.
Key Considerations
- The use of IPC in addition to routine care (aspirin and hydration) has been shown to reduce the risk of DVT in immobile stroke patients, with an adjusted OR of 0.65 (95% CI, 0.51–0.84; P=0.001) 1.
- Contraindications to IPC include leg conditions such as dermatitis, gangrene, severe edema, venous stasis, severe peripheral vascular disease, postoperative vein ligation, or grafting, as well as existing swelling or other signs of an existing DVT 1.
- Pharmacological DVT prophylaxis with heparin or low molecular weight heparin may be considered on a case-by-case basis after 24 hours, but its benefits in reducing DVT risk must be carefully weighed against the increased risk of bleeding complications, particularly in patients already on dual antiplatelet therapy (DAPT) with Plavix and aspirin 1.
Recommendations
- Apply pneumatic compression devices to both lower extremities as soon as possible after admission for patients with acute CVA who are at risk of DVT.
- Encourage early mobilization when safe to reduce the risk of DVT and improve overall outcomes.
- Consider pharmacological DVT prophylaxis with heparin or low molecular weight heparin after 24 hours for patients with restricted mobility and low bleeding risk, but only after careful evaluation of the individual patient's risk factors and bleeding risk.
From the Research
Deep Vein Thrombosis Prophylaxis
The recommended deep vein thrombosis (DVT) prophylaxis in patients recently started on Plavix (clopidogrel) and Aspirin (acetylsalicylic acid) for acute cerebrovascular accident (CVA) is not directly addressed in the provided studies. However, the following information can be gathered:
- DVT prophylaxis is essential in the management of patients at risk of venous thromboembolism (VTE) 2, 3, 4.
- Modalities available for DVT prophylaxis include pharmacologic anticoagulation, mechanical prophylaxis, and inferior vena cava (IVC) filters 2.
- Pharmacologic agents such as low-dose heparin (LDH), low molecular weight heparin (LMWH), and factor Xa inhibitors can be used for DVT prophylaxis 2, 4.
- Mechanical prophylaxis methods include graduated compression stockings (GCSs), pneumatic compression devices (PCDs), and A-V foot pumps 2, 3, 5.
- The use of aspirin and compression devices has been compared to low-molecular-weight heparin and PCD for VTE prophylaxis in orthopedic oncology patients, with no significant difference in DVT rate found between the two groups 6.
Considerations for Patients on Plavix and Aspirin
Patients on Plavix and Aspirin may have an increased risk of bleeding, which should be taken into consideration when selecting a DVT prophylaxis strategy 5.
- Mechanical devices, such as graduated compression stockings and intermittent pneumatic compression, may be recommended for patients with a high risk of bleeding or contraindication to anticoagulants 5.
- The efficacy of mechanical devices for DVT prevention is well documented in surgery, but the evidence is insufficient for the prevention of pulmonary embolism and in other settings, including stroke 5.