No short- or long-term net benefit of early anticoagulant therapy after ischaemic stroke

Cochrane Pre-hospital and Emergency Care

No short- or long-term net benefit of early anticoagulant therapy

SOURCE
Wang X, Ouyang M, Yang J, Song L, Yang M, Anderson CS. (2021)
Anticoagulants for acute ischaemic stroke.
Cochrane Database Syst Rev 10:CD000024

CONTEXT
Stroke is the third leading cause of premature death worldwide. Most strokes are ischaemic. The use of anticoagulants could be proposed to improve patient outcomes and limit recurrence without increasing the risk of bleeding events.

CLINICAL QUESTION
Is early administration of anticoagulants in patients with suspected or confirmed acute ischaemic stroke effective in terms of mortality, disability and recurrence? Does this administration limit the occurrence of venous thrombosis events without increasing the risk of bleeding?

BOTTOM LINE
Early anticoagulation does not reduce the occurrence of death or long-term disability, regardless of the dose and type of anticoagulant (high-certainty evidence). Anticoagulant therapy started within the first 14 days after stroke onset does not reduce the risk of early death from all causes (low-certainty evidence). Although early anticoagulant therapy is associated with a decrease in the number of recurrent ischaemic strokes (moderate-certainty evidence), it is also associated with an increase in symptomatic intracranial haemorrhages (moderate-certainty evidence). Early anticoagulation reduces the occurrence of symptomatic pulmonary embolisms (moderate-certainty evidence) but unfortunately increases the
occurrence of extracranial haemorrhages (moderate-certainty evidence).

CAVEAT
This is an update of a Cochrane Review first published in 1995. The anticoagulants tested are standard unfractionated heparin, low molecular weight heparins, heparinoids, oral anticoagulants and thrombin inhibitors. The majority of studies were published more than twenty years ago, well before the creation of neurovascular units and with different therapeutic protocols. Ninety percent of the data come from anticoagulant treatments initiated within the first 48 hours of disease onset. It might be reasonable to consider safer alternatives for immobile patients such as aspirin, pneumatic restraints or early mobilization.

AUTHORS
D. Meyran
daniel.meyran@me.com
Groupement Santé, SMUR
Bataillon de Marins Pompiers de Marseille
Marseille, France
P. Miroux
patrick_miroux@yahoo.fr
Département de médecine d'urgence
Angers, France
K. Magee
Kirk.magee@dal.ca
Dalhousie University, Halifax Infirmary
Nova Scotia, Canada