Is heparin (Heparin) drip recommended for acute or subacute stroke?

Heparin Drip is Not Recommended for Acute or Subacute Stroke

Dose-adjusted, unfractionated heparin (heparin drip) is not recommended for acute or subacute ischemic stroke as it shows no efficacy in reducing morbidity, mortality, or early recurrent stroke while increasing the risk of bleeding complications. 1

Evidence Against Heparin Drip in Stroke

The American Academy of Neurology and American Stroke Association guidelines provide clear recommendations against using heparin drip in acute stroke:

• Dose-adjusted unfractionated heparin (heparin drip) has not been shown to reduce morbidity, mortality, or early recurrent stroke in acute stroke patients 1
• The potential risks of bleeding complications outweigh any theoretical benefits 1
• This recommendation applies to all stroke subtypes, including cardioembolic, large vessel atherosclerotic, and "progressing" stroke 1

Recommended Alternatives for Acute Stroke Management

First-line treatment:

• Aspirin (160-325 mg/day) should be administered within 24-48 hours after stroke onset 1, 2
• Aspirin reduces stroke mortality and decreases morbidity by reducing early recurrent stroke 2
• For patients receiving IV alteplase (tPA), aspirin should be delayed until 24 hours after thrombolysis 2

DVT Prophylaxis:

• Low-dose subcutaneous unfractionated heparin or LMWH may be considered only for DVT prophylaxis in at-risk patients 1
• This is not for stroke treatment but for preventing venous thromboembolism during hospitalization 1
• The risk-benefit ratio must be carefully assessed, as even prophylactic doses increase bleeding risk 3

Special Considerations and Subgroups

Despite historical beliefs that heparin might benefit specific stroke subtypes (particularly cardioembolic stroke), evidence does not support this practice:

• No stroke subgroup has demonstrated clear benefit from heparin drip therapy 1
• Even in patients with atrial fibrillation, high-dose LMWH (dalteparin) was not more efficacious than aspirin 1
• The International Stroke Trial found no significant differences between low-dose heparin and no heparin in 14-day mortality or pulmonary embolism 1

Potential Exceptions (Limited Evidence)

One small case series suggested potential benefit of IV heparin in the very specific scenario of non-occlusive intraluminal thrombus 4, but this represents insufficient evidence to override the strong guideline recommendations against routine heparin use.

Common Pitfalls to Avoid

1. Assuming heparin prevents early recurrent stroke: While it may reduce ischemic stroke recurrence, this benefit is negated by increased hemorrhage risk 1, 5

2. Using heparin for "stroke in evolution": No evidence supports this common practice 6

3. Confusing DVT prophylaxis with stroke treatment: Low-dose subcutaneous heparin for DVT prevention is different from therapeutic heparin drip for stroke treatment 1

4. Assuming benefit in cardioembolic stroke: Despite theoretical benefits, evidence does not support heparin use even in this subgroup 1, 7

In conclusion, aspirin remains the evidence-based antithrombotic treatment of choice for acute ischemic stroke, while heparin drip should be avoided due to unfavorable risk-benefit profile.