Anticoagulants for acute ischaemic stroke

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Abstract
Objectives Objective: To determine whether anticoagulant therapy is effective and safe in the early treatment of patients with acute presumed or confirmed ischaemic stroke. Search methods Data Sources: Cochrane Stroke Review Group search strategy plus personal contact with several drug companies marketing anticoagulant agents. Selection criteria Study selection: All completed, unconfounded, truly randomized controlled trials comparing the value of early (started within two weeks of stroke onset) anticoagulant treatment against control in patients with acute presumed or confirmed ischaemic stroke. Twelve trials were identified. Data collection and analysis Data extraction: The number of patients with the following outcomes were sought: deep venous thrombosis, pulmonary embolism, death (from all causes and from vascular causes), intracranial haemorrhage, extracranial haemorrhage, recurrent stroke, myocardial infarction and survival free of disability. All analyses were, as far as possible, "intention‐to‐treat". Main results Data synthesis: The regimens compared with control were: standard unfractionated heparin (six trials, 752 patients); low‐molecular‐weight heparin/heparinoid (four trials, 268 patients); oral anticoagulants (two trials, 81 patients). Allocation to anticoagulant therapy wasassociated with a highly significant 81% (SD 8, 2p <0.00001) reduction in the odds of deep venous thrombosis (16.8% anticoagulant therapy vs 53.5% control). There were no statistically significant differences between patients allocated to anticoagulant therapy compared to control in the frequency of death, pulmonary embolism, intracranial haemorrhage, extracranial haemorrhage or recurrent stroke, but the numbers were small and so the confidence intervals were wide. Clinically important benefits or risks with anticoagulant therapy could not, therefore, be reliably excluded. There were no reliable data on the effect of treatment on the occurrence of myocardial infarction or survival free of disability. Authors' conclusions Conclusions: Early institution of anticoagulant therapy after stroke was associated with substantial reductions in deep venous thrombosis. However, the balance of risk and benefit from early anticoagulant therapy (including prophylactic therapy for venous thromboembolism) was unclear, particularly with respect to important clinical outcomes (death, intracranial haemorrhage, disability). Large randomized studies comparing anticoagulant therapy with control in tens of thousands of patients are required (and are now underway).

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