Enoxaparin (Lovenox) for VTE Prophylaxis in Hospitalized Stroke Patients on Dual Antiplatelets
Patients with stroke-like symptoms already on aspirin and Plavix require additional VTE prophylaxis with either enoxaparin or intermittent pneumatic compression devices if they are immobile or at high risk for venous thromboembolism, as dual antiplatelet therapy alone does not provide adequate DVT/PE prevention. 1
Risk Assessment for VTE Prophylaxis
All hospitalized stroke patients must be assessed for VTE risk immediately upon admission. 1 High-risk features include:
- Inability to move one or both lower limbs 1
- Inability to mobilize independently 1
- Previous history of venous thromboembolism 1
- Dehydration 1
- Comorbidities such as cancer 1
VTE Prophylaxis Options for High-Risk Patients
For patients meeting high-risk criteria, start either thigh-high intermittent pneumatic compression (IPC) devices OR pharmacological prophylaxis immediately if no contraindication exists (e.g., intracranial hemorrhage, systemic bleeding). 1 Current evidence does not demonstrate superiority of one approach over the other. 1
Pharmacological Prophylaxis with Enoxaparin
Low-molecular-weight heparin (enoxaparin) should be considered for patients with acute ischemic stroke at high risk of VTE. 1 The PREVAIL trial demonstrated that enoxaparin 40 mg subcutaneously once daily reduced VTE risk by 43% compared to unfractionated heparin (10% vs 18%, p=0.0001), with similar bleeding rates between groups (1% symptomatic intracranial and major extracranial hemorrhage in both). 2
- For patients with renal failure, use unfractionated heparin instead of enoxaparin 1
- Enoxaparin can be safely administered alongside aspirin and clopidogrel for VTE prophylaxis, as the indication differs from stroke treatment 1
Mechanical Prophylaxis with IPC
If IPC devices are selected:
- Apply within the first 24 hours after admission 1
- Assess skin integrity daily 1
- Discontinue when patient becomes independently mobile, at discharge, if adverse effects develop, or by 30 days (whichever comes first) 1
- If IPC is considered after the first 24 hours, obtain venous leg Doppler studies first 1
Critical Timing and Contraindications
For patients with intracerebral hemorrhage, avoid pharmacological VTE prophylaxis for at least 48 hours after onset. 1 After 48 hours, treatment may be initiated following careful risk assessment and repeat brain imaging demonstrating hematoma stability. 1
Antiplatelet therapy (aspirin and clopidogrel) provides stroke prevention but does NOT adequately prevent DVT/PE in immobilized patients. 1 This is why additional VTE prophylaxis is required. 1
Duration of Prophylaxis
For stroke patients remaining immobile longer than 30 days, continue ongoing VTE prophylaxis with pharmacological agents. 1
What NOT to Do
Anti-embolism stockings alone are NOT recommended for post-stroke VTE prophylaxis. 1 They are ineffective compared to enoxaparin or IPC devices. 1
Adjunctive Measures
Encourage early mobilization (between 24-48 hours if no contraindications) and adequate hydration for all acute stroke patients to help prevent VTE. 1