DVT Prophylaxis After Stroke
Intermittent pneumatic compression (IPC) devices should be the first-line prophylaxis for deep vein thrombosis (DVT) in immobile stroke patients, with prophylactic-dose low-molecular-weight heparin (LMWH) as an alternative starting 2-4 days after stroke onset. 1
Risk Assessment for DVT in Stroke Patients
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
Mechanical Prophylaxis Options
Recommended:
- Intermittent pneumatic compression (IPC) devices
- Should be applied as soon as possible and within the first 24 hours after admission
- Continue until patient becomes independently mobile, is discharged, develops adverse effects, or for 30 days (whichever comes first) 1
- Provides significant reduction in DVT risk (9.6% vs 14.0%) and improved 6-month survival 1
Not Recommended:
- Anti-embolism stockings alone
Pharmacological Prophylaxis Options
For Ischemic Stroke:
Low-molecular-weight heparin (LMWH) (preferred)
Unfractionated heparin (UFH)
- Alternative for patients with renal failure
- Typical dose: 5,000 units 2-3 times daily 1
For Hemorrhagic Stroke:
- Intermittent pneumatic compression should be used initially
- Low-dose subcutaneous LMWH may be started between days 2-4 after documenting cessation of active bleeding 2, 4
Duration of Prophylaxis
- Continue prophylaxis throughout the hospital stay or until the patient regains mobility 1
- For patients remaining immobile beyond 30 days, consider ongoing pharmacological prophylaxis 1
- Evidence from the CLOTS trial suggests that while most DVTs develop within the first week, some develop later, supporting prophylaxis for at least 4 weeks 5
Additional Preventive Measures
- Early mobilization as soon as the patient is medically stable 1
- Adequate hydration for all acute stroke patients 1, 3
- Regular skin integrity assessment for patients using IPC devices 1
Monitoring and Special Considerations
- If IPC is considered after the first 24 hours of admission, venous leg Doppler studies should be considered 1
- For patients using IPC devices, daily skin assessment is essential 1
- Consult a wound care specialist if skin breakdown begins during IPC therapy 1
- DVTs most commonly affect the weaker/paralyzed leg (73% of cases) 5
Comparative Effectiveness
When comparing prophylactic options:
- IPC is superior to anti-embolic stockings 6
- LMWH is more effective than UFH (33 fewer symptomatic DVTs and 5 fewer pulmonary emboli per 1,000 patients) 1
- Combined mechanical and pharmacological prophylaxis may provide additional benefit in high-risk patients 6
The strongest evidence supports the use of IPC devices, with prophylactic anticoagulation as an alternative or additional measure depending on bleeding risk and mobility status 1, 7.