From the Guidelines
VTE prophylaxis is generally recommended for stroke rule-out patients who are immobilized or have limited mobility, as stated in the 2018 guidelines for the early management of patients with acute ischemic stroke 1. For these patients, low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily or unfractionated heparin 5000 units subcutaneously every 8-12 hours should be initiated as soon as possible after admission, assuming there are no contraindications like active bleeding or high bleeding risk. Some key points to consider include:
- Mechanical prophylaxis with intermittent pneumatic compression devices should be used for patients with contraindications to pharmacological prophylaxis, as recommended by the Canadian Stroke Best Practice Recommendations for acute stroke management 1.
- The prophylaxis should continue throughout the hospital stay and potentially for a short period after discharge if mobility remains limited.
- Individual risk assessment using tools like the Padua or IMPROVE VTE risk scores can help guide decisions for specific patients, as suggested by the American College of Physicians' guideline on venous thromboembolism prophylaxis in hospitalized patients 1.
- Early mobilization and adequate hydration should be encouraged for all acute stroke patients to help prevent venous thromboembolism, as recommended by the Canadian Stroke Best Practice Recommendations for acute stroke management 1.
From the Research
VTE Prophylaxis in Stroke Rule Out Patients
- The need for VTE prophylaxis in stroke rule out patients is supported by several studies 2, 3, 4, 5, 6.
- A study published in the Journal of Thrombosis and Haemostasis found that enoxaparin was associated with a 37% reduction in total VTE and a 62% reduction in symptomatic VTE compared to unfractionated heparin in hospitalized medical patients, including those with stroke 2.
- The European Stroke Organisation guidelines recommend the use of intermittent pneumatic compression (IPC) in immobile patients with acute ischemic stroke, and suggest that prophylactic anticoagulation with unfractionated heparin (UFH) or low molecular weight heparin (LMWH) should be considered in patients with a high risk of VTE 3.
- A study published in ClinicoEconomics and Outcomes Research found that the use of enoxaparin for VTE prophylaxis in acute ischemic stroke patients was associated with a better clinical benefit-to-risk ratio and reduced costs compared to unfractionated heparin 4.
- The PREVAIL study, published in The Lancet, found that enoxaparin reduced the risk of VTE by 43% compared to unfractionated heparin in patients with acute ischemic stroke, with a similar incidence of bleeding complications 5.
- A subanalysis of the PREVAIL study published in Stroke found that the use of enoxaparin was not associated with poorer long-term neurological outcomes or increased rates of symptomatic intracranial hemorrhage compared to unfractionated heparin 6.
Key Findings
- Enoxaparin is associated with a reduced risk of VTE compared to unfractionated heparin in patients with acute ischemic stroke 2, 5.
- The use of IPC is recommended in immobile patients with acute ischemic stroke 3.
- Prophylactic anticoagulation with UFH or LMWH should be considered in patients with a high risk of VTE 3.
- The use of enoxaparin is associated with a better clinical benefit-to-risk ratio and reduced costs compared to unfractionated heparin 4.
- The incidence of bleeding complications is similar between enoxaparin and unfractionated heparin 5, 6.