Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-jn8rn Total loading time: 0 Render date: 2024-12-26T13:06:37.789Z Has data issue: false hasContentIssue false

Chapter 10 - Acute Anticoagulant Therapy for the Treatment of Acute Ischaemic Stroke and Transient Ischaemic Attack

from Part III - Acute Treatment of Ischaemic Stroke and Transient Ischaemic Attack

Published online by Cambridge University Press:  15 December 2020

By
Xinyi Leng  and
Lawrence Wong
Edited by
Jeffrey L. Saver  and
Graeme J. Hankey
Jeffrey L. Saver
Affiliation:
David Geffen School of Medicine, University of Ca
Graeme J. Hankey
Affiliation:
University of Western Australia, Perth
Get access

Summary

In broad, relatively unselected patients with acute ischaemic stroke, immediate high-dose anticoagulation therapy to avert early stroke progression or recurrence reduces recurrent ischaemic stroke compared with control during the treatment period but this benefit is offset by an increase in intracranial haemorrhage (ICH) and extracranial haemorrhage (ECH). Immediate antiplatelet therapy has similarly efficacy as anticoagulation in averting early stroke progress or recurrence, and is safer when used as an immediate agent (see Chapter 9). In acute ischaemic stroke patients with atrial fibrillation, after start of antiplatelet therapy on presentation, early switchover to anticoagulation therapy 2 -14 days after stroke onset is reasonable, but caution should be taken in certain subgroups of patients with high risk of bleeding. In broad, relatively unselected ischaemic stroke patients, low-dose, venous prophylaxis anticoagulation compared with control reduces the occurrence of asymptomatic deep venous thrombosis (DVT) and shows a tendency to reduce pulmonary embolism, but also shows off-setting tendencies to increase ICH and ECH, without conferring a clear net clinical benefit. Low-molecular-weight heparins (LMWH) or heparinoids, compared with unfractionated heparin, appear to further decrease the occurrence of DVT and PE but potentially further increase ICH, but there are too few data to provide reliable information.

Keywords

Anticoagulantheparinlow-molecular-weight heparinprogressionrecurrent stroke haemorrhagic transformationintracranial haemorrhageatrial fibrillationacute ischaemic stroketransient ischaemic attackmanagementtreatment
Type
Chapter
Information
Stroke Prevention and Treatment
An Evidence-based Approach
 , pp. 179 - 198
Publisher: Cambridge University Press
Print publication year: 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Abdul-Rahim, AH, Fulton, RL, Frank, B, Tatlisumak, T, Paciaroni, M, Caso, V, et al. (2015). Association of improved outcome in acute ischaemic stroke patients with atrial fibrillation who receive early antithrombotic therapy: analysis from VISTA. Eur J Neurol, 22, 1048–55.Google ScholarPubMed
Amarenco, P, Lavallée, PC, Labreuche, J. (2016). One-year risk of stroke after transient ischemic attack or minor ischemic stroke. N Engl J Med, 374, 1533–42.Google Scholar
Ay, H, Gungor, L, Arsava, EM, Rosand, J, Vangel, M, Benner, T, et al. (2010). A score to predict early risk of recurrence after ischemic stroke. Neurology, 74, 128–35.CrossRefGoogle ScholarPubMed
Berge, E, Abdelnoor, M, Nakstad, PH, Sandset, PM on behalf of the Heparin in Acute Embolic Stroke Trial (HAEST) Study Group. (2000). Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet, 355, 1205–10.Google Scholar
Cazzato, G, Zorzon, M, Mase, G, Antonutto, L, Iona, LG. (1989). Il mesoglicano nelle ischemie cerebrali acute a focolaio [Mesoglycan in the treatment of acute cerebral infarction]. Rivista di Neurologia, 59, 121–6.Google Scholar
Cerebral Embolism Study Group. (1983). Immediate anticoagulation of embolic stroke: a randomized trial. The Cerebral Embolism Study Group. Stroke, 14, 668–76.Google Scholar
Chimowitz, MI, Lynn, MJ, Derdeyn, CP, Derdeyn, CP, Turan, TN, Fiorella, D, et al. (2011). Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med, 365, 993–1003Google Scholar
Dennis, M, Caso, V, Kappelle, LJ, Pavlovic, A, Sandercock, P, for the European Stroke Organisation. (2016). European Stroke Organisation (ESO) guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke. Eur Stroke J, 1, 6–19.Google Scholar
Duke, RJ, Turpie, AGG, Bloch, RF, Trebilcock, RG. (1983). Clinical trial of low-dose subcutaneous heparin for the prevention of stroke progression: natural history of acute partial stroke and stroke-in-evolution. In Reivich, M, Hurtig, HI, eds., Cerebrovascular Disease. New York: Raven Press, pp. 399–405.Google Scholar
Duke, RJ, Bloch, RF, Turpie, AGG, Trebilcock, RG, Bayer, N. (1986). Intravenous heparin for the prevention of stroke progression in acute partial stable stroke. Ann Intern Med, 105, 825–8.Google Scholar
Elias, A, Milandre, L, Lagrange, G, Aillaud, MF, Alonzo, B, Toulemonde, F, et al. (1990). Prevention of deep venous thrombosis of the leg by a very low molecular weight heparin fraction (CY 222) in patients with hemiplegia following cerebral infarction: a randomized pilot study (30 patients). Revue de Médecine Interne, 11, 95–8.Google Scholar
Hommel, M, for the FISS-bis Investigators Group. (1998). Fraxiparine in Ischaemic Stroke Study (FISS bis). Cerebrovasc Dis, 8(Suppl 4), 19.Google Scholar
Hong, KS, Kwon, SU, Lee, SH, Lee, JS, Kim, YJ, Song, TJ, et al. (2017). Rivaroxaban vs warfarin sodium in the ultra-early period after atrial fibrillation-related mild ischemic stroke: a randomized clinical trial. JAMA Neurol, 74, 1206–15.Google Scholar
International Stroke Trial Collaborative Group. (1997). The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. Lancet, 349, 1569–81.Google Scholar
Johansson, E, Wester, P. (2014). Recurrent stroke risk is high after a single cerebrovascular event in patients with symptomatic 50–99% carotid stenosis: a cohort study. BMC Neurol, 14, 23.Google Scholar
Kernan, WN, Ovbiagele, B, Black, HR, Bravata, DM, Chimowitz, MI, Ezekowitz, MD, et al. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45, 2160–2236.CrossRefGoogle ScholarPubMed
Kwiecinski, H, Pniewski, J, Kaminska, A, Szyluk, B. (1995). A randomized trial of fraxiparine in acute ischaemic stroke. Cerebrovasc Dis, 5, 234.Google Scholar
LaMonte, MP, Nash, ML, Wang, DZ, Woolfenden, AR, Schulz, J, Hursting, MJ, et al. (2004). Argatroban anticoagulation in patients with acute ischemic stroke (ARGIS-1). Stroke, 35, 1677–82.CrossRefGoogle ScholarPubMed
Lansberg, MG, O’Donnell, MJ, Khatri, P, Lang, ES, Nguyen-Huynh, MN, Schwartz, NE, et al. (2012). Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141, e601S–636S.CrossRefGoogle ScholarPubMed
Liu, L, Wong, KSL, Leng, X, Pu, Y, Wang, Y, Jing, J, et al. (2015). Dual antiplatelet therapy in stroke and ICAS Subgroup analysis of CHANCE. Neurology, 85, 1154–62.CrossRefGoogle ScholarPubMed
McCarthy, ST, Turner, J. (1986). Low-dose subcutaneous heparin in the prevention of deep-vein thrombosis and pulmonary emboli following acute stroke. Age Ageing, 15, 84–8.Google Scholar
McCarthy, ST, Turner, JJ, Robertson, D, Hawkey, CJ, Macey, DJ. (1997). Low dose heparin as a prophylaxis against deep-vein thrombosis after acute stroke. Lancet, ii:800–1.Google Scholar
Paciaroni, M, Agnelli, G, Falocci, N, Caso, V, Becattini, C, Marcheselli, S, et al. (2015). Early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation: effect of anticoagulation and its timing: the RAF study. Stroke, 46, 2175–82.Google Scholar
Paciaroni, M, Agnelli, G, Micheli, S, Caso, V. (2007). Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials. Stroke, 38, 423–30.CrossRefGoogle ScholarPubMed
Pambianco, G, Orchard, T, Landau, P. (1995). Deep vein thrombosis: prevention in stroke patients during rehabilitation. Arch Phys Med Rehabil, 76, 324–30.Google Scholar
Pince, J. (1981). Thromboses veineuses des membres inferieurs et embolies pulmonaires au cours des accidents vasculaires cerebraux. A propos d’un essai comparitif de traitement preventif. These pour le doctorat d’état en médecine, Toulouse: Université Paul Sabatier.Google Scholar
Prins, MH, Gelsema, R, Sing, AK, van Heerde, LR, den Ottolander, GJ. (1989). Prophylaxis of deep venous thrombosis with a low-molecular-weight heparin (Kabi 2165/Fragmin) in stroke patients. Haemostasis, 19, 245–50.Google Scholar
Rothwell, PM. (2008). Prediction and prevention of stroke in patients with symptomatic carotid stenosis: the high-risk period and the high-risk patient. Eur J Vasc Endovasc Surg, 35, 255–63.Google Scholar
Sandercock, PAG, Counsell, C, Kane, EJ. (2015). Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev, 3. CD000024.Google Scholar
Sandercock, PAG, Leong, TS. (2017). Low-molecular-weight heparins or heparinoids versus standard unfractionated heparin for acute ischaemic stroke. Cochrane Database Syst Rev, 4. CD000119. doi:10.1002/14651858.CD000119.pub4.Google Scholar
Sandset, PM, Dahl, T, Stiris, M, Rostad, B, Scheel, B, Abildgaard, U. (1990). A double-blind and randomized placebo-controlled trial of low molecular weight heparin once daily to prevent deep-vein thrombosis in acute ischemic stroke. Semin Thromb Hemost, 16(Suppl), 25–33.Google Scholar
Saxena, R, Lewis, S, Berge, E, Sandercock, PAG, Koudstaal, PJ, for the International Stroke Trial Collaborative Group. (2001). Risk of early death and recurrent stroke and effect of heparin in 3169 patients with acute ischemic stroke and atrial fibrillation in the International Stroke Trial. Stroke, 32, 2333–7.Google Scholar
Seiffge, DJ, Werring, DJ, Paciaroni, M, Dawson, J, Warach, S, Milling, TJ, et al. (2019). Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. Lancet Neurol, 18, 117–26.CrossRefGoogle ScholarPubMed
Sherman, DG, Albers, GW, Bladin, C, Fieschi, C, Gabbai, AA, Kase, CS, et al. (2007). The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischaemic stroke (PREVAIL Study): an open-label randomised comparison. Lancet, 369, 1347–55.Google Scholar
Tazaki, Y, Kobayashi, S, Togi, H, Ohtomo, E, Goto, F, Araki, G, et al. (1986). Therapeutic effect of thrombin inhibitor MD-805 in acute phase of cerebral thrombosis – Phase II double-blinded clinical trial (English translation). Rinsho to Kenkyu, 63, 3047–57.Google Scholar
TOAST Investigators. (1998). Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischaemic stroke. JAMA, 279, 1265–72.Google Scholar
Turpie, AGG, Levine, MN, Hirsh, J, Carter, CJ, Jay, RM, Powers, PJ, et al. (1987). Double-blind randomised trial of Org 10172 low-molecular-weight heparinoid in prevention of deep-vein thrombosis in thrombotic stroke. Lancet, 1, 523–6.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×