Low-Molecular-Weight Heparin for the Treatment of Acute Ischemic Stroke

Kay, R.; Wong, Ka Sing; Yu, Yuk Ling; Chan, Yuk Wah; Tsoi, Tak Hong; Ahuja, Anil T.; Chan, Frank; Fong, K. Y.; Law, Chun Bong; Wong, Anson; Woo, Jean

doi:10.1056/nejm199512143332402

Cited by 414 publications

(48 citation statements)

References 28 publications

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“…Angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers could have some benefit in term of improved survival at 1 year 3. β‐Blockers showed no effect on survival and recurrence rate,3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 whereas calcium antagonists could be used if coronary vasospasm has been proven during coronary angiogram or with acetylcholine test 32…”

Section: Discussionmentioning

confidence: 99%

“…Current literature shows a higher risk of brain hemorrhage if OAC therapy is started in the first 48 hours after stroke 33, 34. Therefore, OAC therapy could be started between 48 hours and 15 days after ischemic stroke, taking into account the clinical severity, extent of neuroimaging lesions, the risk of cardioembolic recurrence, and risk factors for hemorrhagic transformation.…”

Section: Discussionmentioning

confidence: 99%

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Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Santoro

Stiermaier

Tarantino

et al. 2017

JAHA

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BackgroundLeft ventricular (LV) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome.Methods and ResultsWe enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST‐elevation (56% versus 16%; P<0.001) and higher troponin I levels (10.8±18.3 ng/mL versus 3.5±4.3 ng/mL; P=0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P=0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P=0.99).Conclusions LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Santoro

Stiermaier

Tarantino

et al. 2017

JAHA

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“…During the last 3 years four trials of anticoagulation in acute ischemic stroke have been reported in final [1, 2, 3]or preliminary [4]form. Only one of these studies [1]was able to demonstrate that active treatment was better than placebo in improving clinical outcome after ischemic stroke.…”

Section: Recent Heparin Trials: a Frustrating Experiencementioning

confidence: 99%

Heparin in Acute Ischemic Stroke: The Case for a New Clinical Trial

Chamorro

1999

Cerebrovasc Dis

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“…The long-standing controversy concerning the role of heparin in acute stroke was reignited when the Fraxiparine in Stroke Study (FISS) [8]revealed that early treatment with high-dose nadroparin calcium was associated with a 31% (95% confidence interval [CI]: 10–46%) reduction in death or dependency at 6 months, compared with placebo (45 vs. 65%). The results were not conclusive, however, because the treatment groups were not balanced (by chance, the placebo group had more patients with severe stroke), outcome at 3 months after stroke was not significantly different, and the number of outcome events was small, and thus statistically unstable.…”

Section: Emerging Conceptsmentioning

confidence: 99%

One Year after CAPRIE, IST and ESPS 2

Hankey

1998

Cerebrovasc Dis

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The IST, CAPRIE and ESPS-2 have shown that large collaborative randomised trials can be conducted in stroke medicine and can provide statistically and clinically significant results. They, and other concurrent studies, have highlighted the potential hazards of early anticoagulation, and the effectiveness and safety of early (and continuous) antiplatelet therapy in limiting early stroke recurrence and its consequences. In addition, they have shown that antiplatelet agents with differing mechanisms of action can have different effects, and perhaps additive effects when combined. The ESPRIT trial should delineate the roles of oral anticoagulant therapy, and the combination of aspirin and dipyridamole, in the prevention of stroke due to arterial disease. Future trials will hopefully determine the role in secondary stroke prevention of inhibitors of the platelet GPIIb/IIIa complex (the final common pathway of platelet aggregation), the combination of anitplatelet agents with different mechanisms of action (e.g. aspirin and clopidogrel, aspirin and IIb/IIIa inhibitors), the combination of antiplatelet agents and oral anticoagulants (which may simultaneously modify platelet function and fibrin production), and the combination of antithrombotic and cholesterol-lowering (statin) medications.

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Low-Molecular-Weight Heparin for the Treatment of Acute Ischemic Stroke

Abstract: For patients with ischemic stroke treated within 48 hours of the onset of symptoms, low-molecular-weight heparin was effective in improving outcomes at six months.

Cited by 414 publications

References 28 publications

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Heparin in Acute Ischemic Stroke: The Case for a New Clinical Trial

One Year after CAPRIE, IST and ESPS 2

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