Page 95 - ITPS-7-4

INNOSC Theranostics and
Pharmacological Sciences LMWH for VTE prophylaxis in acute stroke patients

the initial few weeks. Clinically, about 5% of hospitalized initiation in cardioembolic strokes has to be established.
18
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patients have definite DVT. Similarly, about 1 – 2% of The European Stroke Organization (ESO) guidelines
4
hospitalized stroke patients were clinically diagnosed with recommend that prophylactic anticoagulation with UFH
PEs, but in some studies, the incidence is about 10%. and LMWH should be considered in immobile patients
5
Moreover, Warlow et al. revealed PE as an identifiable cause with ischemic stroke in whom the benefits of reducing the
in about half of the patients dying after a stroke, based on risk of VTE are significant enough to offset the increased
4
data collected from a hospital where autopsies were more risk of intracranial and extracranial bleeding. This was
conventional. Therefore, clinicians are expected to assess also suggested by Khan et al. following a systemic review of
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VTE risk among stroke patients and provide the most literature on deep vein thrombosis in acute stroke; LMWH
effective and safe prophylaxis. was effective in reducing DVT and PE in patients with
Hemorrhagic transformation (HT) is another stroke at the cost of a slightly increased risk of intracerebral
common complication in acute ischemic stroke, and its and extracranial bleeding. 19
rate of occurrence can range from <1%. The severity The CLOTS 1 and 2 trials showed that GCSs were
7-9
of hemorrhage may range from a few petechiae to a large ineffective in preventing VTE or improving functional
hematoma with or without space-occupying effects. outcomes in stroke. The CLOTS 3 trial showed that
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Based on the classification by the European Cooperative intermittent pneumatic compression (IPC) using
Acute Stroke Study, each HT category is divided into two sequential compression with venous refill technology
subtypes, with each featuring distinctive characteristics in immobile patients in the first 30 days after stroke is
(Table 1). 10 an effective treatment for reducing proximal DVT and
HT does not usually have a significant impact on patient improves survival but not functional outcomes. 21
prognosis, but massive parenchymal hematoma, albeit It is challenging for patients with a high risk of VTE
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rare, is life-threatening. The mechanism of HT formation and low risk of bleeding to use anticoagulants in a selective
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during ischemic stroke is thought to be related to the early manner after stroke because the factors that predict VTE
disruption of the blood–brain barrier (BBB). The BBB and those predicting bleeding risk overlap. 22,23 According
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is a physiological barrier between the brain parenchyma to Geeganage et al., LMWH minimizes the risk of recurrent
and brain circulation that nourishes brain tissue. It filters ischemic stroke, DVT, and PE; however, on the other
various substances from the brain to the blood and protects hand, they increase the risk of symptomatic intracranial
the brain. 14,15 The other factors that might influence HT and extracranial hemorrhage. In stroke, the benefits
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are histological changes, vascular occlusion, collateral of LMWH are often offset by its harms; according to the
circulation, and infarct size. 16,17 data from randomized controlled trials of subcutaneous
Post-stroke VTE prophylaxis can be achieved with heparins, there was no noticeable effect of anticoagulants
non-pharmacological and pharmacological strategies. on death or disability measured several months after
25-27
Non-pharmacological or physical methods consist of stroke.
graduated compression stockings (GCSs) and intermittent 1.1. Study justification
pneumatic compression devices (IPCDs). The use of
blood thinners such as low-molecular-weight heparin Poor compliance with IPCDs among admitted patients
(LMWH) and unfractionated heparins (UFH) come with acute stroke was common at our unit. The poor
under pharmacological interventions. HT should be compliance can be described as patients not tolerating the
taken into account when the timing for anticoagulation device, increased risk of falls, patients being ignorant that
they attempt to stand without support with the IPCDs still
on, and forgetfulness in reattaching IPCDs after care (e.g.,
Table 1. ECASS classification of hemorrhagic events
showering or hygiene) or therapy.
Category Subtype and characteristic Thus, we reviewed the adherence to VTE prophylaxis
Hemorrhagic HI-1: Small petechiae along the margins of the infarct. plans formulated for our stroke unit by auditing
infarction HI-2: Confluent petechiae within the infarcted area but compliance with IPCD use in 2021. The auditing process
no space-occupying effect. was completed in two parts:
Parenchymal PH-1: Blood clots in 30% or less of the infarcted area (1) Audit 1: Review of compliance of VTE prophylaxis
hemorrhage with some slight space-occupying effect.
PH-2: Blood clots in more than 30% of the infarcted prescription using IPCDs in acute stroke patients
area with substantial space-occupying effect. within 72 h of admission
ECASS: European Cooperative Acute Stroke Study, HT: Hemorrhagic (2) Audit 2: Review of compliance of VTE prophylaxis
transformation prescription using IPCDs in acute stroke patients,

Volume 7 Issue 4 (2024) 2 doi: 10.36922/itps.3250