From the Guidelines
DVT prophylaxis with Lovenox after acute hemorrhagic CVA should be delayed for 24-48 hours after the bleeding has stabilized, as recommended by the 2022 guideline from the American Heart Association/American Stroke Association 1. When considering DVT prophylaxis, it is essential to weigh the risk of venous thromboembolism against the risk of expanding the intracranial hemorrhage.
- The in-hospital incidence of thromboembolic complications in patients with ICH is approximately 7%, with a 4-fold higher risk of DVT compared to patients with acute ischemic stroke 1.
- Intermitent pneumatic compression (IPC) devices are recommended for VTE prophylaxis in nonambulatory patients with spontaneous ICH, starting on the day of diagnosis, as they have been shown to be more effective than compression stockings in reducing VTE 1.
- Low-dose UFH or LMWH, such as Lovenox, can be useful in reducing the risk of PE, but should be initiated at 24 to 48 hours from ICH onset to optimize the benefits of preventing thrombosis relative to the risk of hemorrhage expansion 1.
- The decision to start Lovenox must balance the risk of venous thromboembolism against the risk of expanding the intracranial hemorrhage, taking into account factors such as patient weight, renal function, and bleeding risk.
- Regular neurological assessments and repeat imaging may be necessary to monitor for any signs of hemorrhage expansion after initiating prophylaxis.
- For patients with very high bleeding risk, extended use of mechanical prophylaxis alone may be considered until the risk-benefit ratio favors pharmacological intervention 1.
From the Research
Considerations for DVT Prophylaxis with Lovenox after Acute Hemorrhagic CVA
- The use of enoxaparin (Lovenox) for deep vein thrombosis (DVT) prophylaxis in patients with acute hemorrhagic cerebral vascular accident (CVA) requires careful consideration of the risks and benefits 2, 3, 4, 5, 6.
- Studies have shown that enoxaparin can reduce the risk of venous thromboembolism (VTE) in patients with acute ischemic stroke, but the optimal duration of prophylaxis is unknown 3, 5, 6.
- A study comparing enoxaparin with unfractionated heparin for VTE prophylaxis in patients with acute ischemic stroke found that enoxaparin was associated with a reduced risk of VTE, but an increased risk of major bleeding 6.
- Another study found that extended-duration thromboprophylaxis with enoxaparin was associated with reduced VTE risk and increased major bleeding in patients with ischemic stroke 5.
- The decision to resume chemical DVT prophylaxis in patients with intracranial hemorrhage should be based on individual patient risk factors and the potential benefits and risks of treatment 4.
- The optimal time to resume chemical DVT prophylaxis in patients with intracranial hemorrhage is not well established, and further research is needed to determine the best approach 4.
Key Findings
- Enoxaparin can reduce the risk of VTE in patients with acute ischemic stroke, but may increase the risk of major bleeding 3, 5, 6.
- The optimal duration of VTE prophylaxis in patients with acute stroke is unknown 3, 5, 6.
- Individual patient risk factors and the potential benefits and risks of treatment should guide the decision to resume chemical DVT prophylaxis in patients with intracranial hemorrhage 4.
Implications for Practice
- Healthcare providers should carefully weigh the risks and benefits of enoxaparin for DVT prophylaxis in patients with acute hemorrhagic CVA 2, 3, 4, 5, 6.
- Further research is needed to determine the optimal duration of VTE prophylaxis in patients with acute stroke and the best approach to resuming chemical DVT prophylaxis in patients with intracranial hemorrhage 4.