Should a patient with a concern for acute stroke be started on Deep Vein Thrombosis (DVT) prophylaxis?

DVT Prophylaxis in Acute Stroke Patients

Patients with acute stroke should be started on DVT prophylaxis immediately if there are no contraindications, with low-molecular-weight heparin (LMWH) being preferred over unfractionated heparin (UFH) for most patients. 1

Risk Assessment

All stroke patients should be assessed for their risk of developing venous thromboembolism. High-risk patients include:

• Those unable to move one or both lower limbs
• Those unable to mobilize independently
• Previous history of venous thromboembolism
• Dehydration
• Comorbidities such as cancer 1

Prophylaxis Options

Pharmacological Prophylaxis

• LMWH (e.g., enoxaparin): Preferred first-line option for most patients with acute ischemic stroke at high risk of VTE

  • Dosage: 40 mg subcutaneously once daily 1
  • Compared to UFH, LMWH results in:
    • 33 fewer symptomatic DVTs per 1,000 patients
    • 5 fewer pulmonary emboli per 1,000 patients 1

• UFH: Alternative for patients with renal failure

  • Dosage: 5,000 units subcutaneously twice daily 1

Mechanical Prophylaxis

• Intermittent Pneumatic Compression (IPC):

  • Should be applied within the first 24 hours after admission
  • Continue until patient becomes independently mobile, is discharged, or up to 30 days (whichever comes first)
  • Requires daily skin integrity assessment 1

• Anti-embolism stockings alone: Not recommended for post-stroke VTE prophylaxis 1

Timing Considerations

• For ischemic stroke:

  • Start prophylaxis immediately if no contraindications exist
  • If thrombolytic therapy (r-tPA) was administered, wait 24 hours before starting pharmacological prophylaxis 1

• For hemorrhagic stroke:

  • Pharmacological prophylaxis should be avoided for at least 48 hours after onset
  • May be considered after 48 hours if repeat brain imaging confirms hematoma stability 1, 2
  • IPC can be used immediately 1

Special Considerations

• Early mobilization and adequate hydration should be encouraged for all acute stroke patients to help prevent VTE 1

• Thrombolytic therapy does not protect against DVT risk, with studies showing 21% of patients treated with r-tPA still developing DVT 3

• D-dimer levels within 48 hours of acute stroke may help identify patients at higher risk for DVT development 3

• For patients remaining immobile longer than 30 days, ongoing VTE prophylaxis is recommended 1

Monitoring

• Monitor for signs of bleeding complications with pharmacological prophylaxis
• With IPC, assess skin integrity daily and consult wound care specialists if skin breakdown occurs 1

By implementing appropriate DVT prophylaxis early in the course of stroke management, clinicians can significantly reduce the risk of this potentially life-threatening complication while minimizing adverse effects.