Most patients don't get DVT prophylaxis after hemorrhagic stroke

By Will Boggs MD

NEW YORK (Reuters Health) - Most patients with intracerebral hemorrhage (ICH) do not receive prophylactic anticoagulation for deep vein thrombosis (DVT), a common complication in this setting, researchers say.

"Physicians should consider initiation of prophylactic anticoagulation in their ICH patients based on clinical and radiographic findings of stability within the first few days of presentation," Dr. Shyam Prabhakaran, of Northwestern University, Chicago, told Reuters Health by email. "I think the safety of this practice needs to be emphasized to practitioners. However, a large trial to prove efficacy of this practice may be necessary since guidelines reflect the lack of evidence."

Those guidelines from the American Heart Association/American Stroke Association recommend low-dose unfractionated heparin or low-molecular weight heparin beginning one to four days after ICH onset and after cessation of active bleeding (class IIb, level of evidence B).

Dr. Prabhakaran and colleagues used data from 32,690 adults with spontaneous ICH in the Premier Hospital database to evaluate patient, hospital, and geographic factors associated with prophylactic anticoagulation after ICH.

Overall, 16.5% of the patients during the study period (2006-2010) received prophylactic anticoagulant use, with rates increasing slightly from 15.0% before the 2007 guidelines to 17.5% thereafter (P<0.001).

About 45% of those receiving prophylactic anticoagulation were started before day 2, 67% by day 4, and 91% by day 11, according to the January 8th Stroke online report.

Patients who received anticoagulation were younger, arrived less commonly through the emergency department, and were more frequently black and had Medicaid or were self-pay, compared with patients who never received it.

Compared with Western states, patients treated in the Northeast were 2.3 times as likely and patients treated in the South were almost 1.6 times more likely to receive prophylactic anticoagulation.

Multiple organizations in the U.S., Europe, and Japan recommend consideration of prophylactic anticoagulation for DVT prevention in these patients, but prophylactic anticoagulation is not recommended in the UK or Australia.

"At Academic Medical Centers like ours, it is routine for patients with spontaneous intracerebral hemorrhage to receive low-dose anticoagulation for prevention of DVT on day 2 if the bleeding is stable," Dr. Prabhakaran said.

Dr. Tzu Ching Wu, of the University of Texas-Health Science Center at Houston, has published extensively on stroke and its treatment. He told Reuters Health by email, "ICH patients are at high risk for DVT/PE due to their immobility and the use of pharmacologic DVT prophylaxis in these patients in the first 2-4 days after onset does not lead to hematoma expansion."

"We believe that more studies are needed to study the safety and efficacy of pharmacologic DVT prophylaxis in ICH patients so we can better define guidelines regarding this issue," he said.

"We believe that the use of protocols will increase the use of pharmacologic DVT prophylaxis in these patients," Dr. Wu said. "At our institution we have an ICH protocol that addresses DVT prevention that will ensure that pharmacologic DVT prophylaxis will be instituted when appropriate in ICH patients."

SOURCE: http://bit.ly/1DIrNuj

Stroke 2015.

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