BACKGROUND:Patients with intracerebral hemorrhage (ICH) are at risk for venous thromboembolic (VTE) complications after stroke. The dilemma remains on whether it is safe to initiate low-dose low-molecular weight heparin (LMWH) in patients with ICH without risking expansion of the initial bleed. OBJECTIVE: To critically assess current evidence regarding the safety of low-dose LMWH in the prevention of VTE complications in patients with acute ICH. METHODS: The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular and hospital neurology. RESULTS: A recent quasi-randomized controlled trial was selected for critical appraisal. This trial assigned 75 ICH patients tosubcutaneous LMWH or long compression stockings for deep venous thrombosis and pulmonary embolism prophylaxis. In patients who received low-dose LMWH, there was no hematoma enlargement at 72 hours, day 7, or day 21 compared with the compression stocking group. There was hematoma enlargement in 9 patients at 24 hours, 6 of which were in the LMWH group, but this was before the initiation of the LMWH, which occurred at 48 hours. Adverse events were VTE complications in 4 of 39 patients in the LMWH group and in 3 of 36 patients in the long compression stocking group. CONCLUSIONS: Initiation of low-dose LMWH in spontaneous ICH patients for the purpose of VTE prophylaxis is likely safe. However, a clinical decision based solely on the results of this study cannot be made due to numerous methodological and design shortcomings. A well-designed randomized controlled trial is still needed to answer this clinical question.
RCT Entities:
BACKGROUND:Patients with intracerebral hemorrhage (ICH) are at risk for venous thromboembolic (VTE) complications after stroke. The dilemma remains on whether it is safe to initiate low-dose low-molecular weight heparin (LMWH) in patients with ICH without risking expansion of the initial bleed. OBJECTIVE: To critically assess current evidence regarding the safety of low-dose LMWH in the prevention of VTE complications in patients with acute ICH. METHODS: The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and content experts in the field of vascular and hospital neurology. RESULTS: A recent quasi-randomized controlled trial was selected for critical appraisal. This trial assigned 75 ICHpatients to subcutaneous LMWH or long compression stockings for deep venous thrombosis and pulmonary embolism prophylaxis. In patients who received low-dose LMWH, there was no hematoma enlargement at 72 hours, day 7, or day 21 compared with the compression stocking group. There was hematoma enlargement in 9 patients at 24 hours, 6 of which were in the LMWH group, but this was before the initiation of the LMWH, which occurred at 48 hours. Adverse events were VTE complications in 4 of 39 patients in the LMWH group and in 3 of 36 patients in the long compression stocking group. CONCLUSIONS: Initiation of low-dose LMWH in spontaneous ICHpatients for the purpose of VTE prophylaxis is likely safe. However, a clinical decision based solely on the results of this study cannot be made due to numerous methodological and design shortcomings. A well-designed randomized controlled trial is still needed to answer this clinical question.
Authors: Paul Nyquist; Cynthia Bautista; Draga Jichici; Joseph Burns; Sanjeev Chhangani; Michele DeFilippis; Fernando D Goldenberg; Keri Kim; Xi Liu-DeRyke; William Mack; Kim Meyer Journal: Neurocrit Care Date: 2016-02 Impact factor: 3.210