Journal article
Targeted use of heparin, heparinoids, or low-molecular-weight heparin to improve outcome after acute ischaemic stroke: an individual patient data meta-analysis of randomised controlled trials
Lancet neurology, Vol.12(6), pp.539-545
06/2013
DOI: 10.1016/S1474-4422(13)70079-6
PMCID: PMC3671273
PMID: 23642343
Abstract
Many international guidelines on the prevention of venous thromboembolism recommend targeting heparin treatment at patients with stroke who have a high risk of venous thrombotic events or a low risk of haemorrhagic events. We sought to identify reliable methods to target anticoagulant treatment and so improve the chance of avoiding death or dependence after stroke.
We obtained individual patient data from the five largest randomised controlled trials in acute ischaemic stroke that compared heparins (unfractionated heparin, heparinoids, or low-molecular-weight heparin) with aspirin or placebo. We developed and evaluated statistical models for the prediction of thrombotic events (myocardial infarction, stroke, deep vein thrombosis, or pulmonary embolism) and haemorrhagic events (symptomatic intracranial or significant extracranial) in the first 14 days after stroke. We calculated the absolute risk difference for the outcome “dead or dependent” in patients grouped by quartiles of predicted risk of thrombotic and haemorrhagic events with random effect meta-analysis.
Patients with ischaemic stroke who were of advanced age, had increased neurological impairment, or had atrial fibrillation had a high risk of both thrombotic and haemorrhagic events after stroke. Additionally, patients with CT-visible evidence of recent cerebral ischaemia were at increased risk of thrombotic events. In evaluation datasets, the area under a receiver operating curve for prediction models for thrombotic events was 0·63 (95% CI 0·59–0·67) and for haemorrhagic events was 0·60 (0·55–0·64). We found no evidence that the net benefit from heparins increased with either increasing risk of thrombotic events or decreasing risk of haemorrhagic events.
There was no evidence that patients with ischaemic stroke who were at higher risk of thrombotic events or lower risk of haemorrhagic events benefited from heparins. We were therefore unable to define a targeted approach to select the patients who would benefit from treatment with early anticoagulant therapy. We recommend that guidelines for routine or selective use of heparin in stroke should be revised.
MRC.
Details
- Title: Subtitle
- Targeted use of heparin, heparinoids, or low-molecular-weight heparin to improve outcome after acute ischaemic stroke: an individual patient data meta-analysis of randomised controlled trials
- Creators
- William N Whiteley - Division of Clinical Neurosciences, University of Edinburgh, Bramwell Dott Building, Western General Hospital, Edinburgh, UKHarold P Adams - Department of Neurology, University of Iowa, Iowa City, USAPhilip MW Bath - Division of Stroke, University of Nottingham, Clinical Sciences Building, City Hospital Campus, Nottingham, UKEivind Berge - Oslo University Hospital, Department of Haematology, and University of Oslo, Institute of Clinical Medicine, Oslo, NorwayPer Morten Sandset - Oslo University Hospital, Department of Haematology, and University of Oslo, Institute of Clinical Medicine, Oslo, NorwayMartin Dennis - Division of Clinical Neurosciences, University of Edinburgh, Bramwell Dott Building, Western General Hospital, Edinburgh, UKGordon D Murray - Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UKKa-Sing Lawrence Wong - Division of Neurology, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, ChinaPeter AG Sandercock - Division of Clinical Neurosciences, University of Edinburgh, Bramwell Dott Building, Western General Hospital, Edinburgh, UK
- Resource Type
- Journal article
- Publication Details
- Lancet neurology, Vol.12(6), pp.539-545
- Publisher
- Elsevier Ltd
- DOI
- 10.1016/S1474-4422(13)70079-6
- PMID
- 23642343
- PMCID
- PMC3671273
- ISSN
- 1474-4422
- eISSN
- 1474-4465
- Language
- English
- Date published
- 06/2013
- Academic Unit
- Neurology; Iowa Neuroscience Institute
- Record Identifier
- 9984020655602771
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