Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
27 October 2008
American College of Chest Physicians - Medical Specialty Society
Summary,
GUIDELINE OBJECTIVE(S)
* To make recommendations for the use of antithrombotic and thrombolytic therapy in the management and treatment of ischemic stroke for the purpose of reducing mortality, disability, and complications of ischemic stroke
* To make recommendations for the use of antithrombotic therapy in the prevention of ischemic stroke
TARGET POPULATION
* Adults with or at risk of acute ischemic stroke
* Adults with cerebral venous sinus thrombosis
INTERVENTIONS AND PRACTICES CONSIDERED
Management/Treatment
Treatment of Acute Ischemic Stroke (AIS)
1. Thrombolytic therapy:
* Intravenous (IV) recombinant tissue plasminogen activator (tPA) with strict adherence to eligibility criteria for use
* In selected patients, intra-arterial thrombolytic therapy
2. Antithrombotic therapy:
* Anticoagulation in selected patients
* Early aspirin therapy
* Aspirin therapy in combination with low doses of subcutaneous heparin
Note: The following agents are considered but not recommended for the treatment of acute ischemic stroke: streptokinase (except within the confines of a clinical trial), full-dose anticoagulation, subcutaneous heparin and low-molecular-weight heparins or heparinoids.
Secondary Prevention of Deep Venous Thrombosis (DVT)/Pulmonary Embolism (PE) in Ischemic Stroke Patients
1. Low-dose subcutaneous heparin
2. Low-molecular-weight heparins
3. The heparinoid danaparoid
4. Nonpharmacologic measures:
* Intermittent pneumatic compression devices
* Elastic stockings
Prevention of Strokes
1. Aspirin therapy
2. Aspirin in combination with extended-release dipyridamole
3. Clopidogrel for patients allergic to aspirin
Note: Aspirin in combination with ticlopidine is considered, but not recommended.
Treatment of Cerebral Venous Sinus Thrombosis
1. Unfractionated heparin or low-molecular-weight heparin
2. Oral anticoagulation
Monitoring
1. International normalized ratio (INR)
2. Computed tomography (CT)
3. Magnetic resonance imaging (MRI)
MAJOR OUTCOMES CONSIDERED
Efficacy and safety of treatment, as defined by the following:
* Rates of mortality and disability from ischemic stroke
* Functional status
* Rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) secondary to ischemic stroke
* Rates of adverse events from treatment, such as intracerebral hemorrhages (ICH)
* Relative risk reduction of recurrent stroke and other vascular events (prevention)
American College of Chest Physicians - Medical Specialty Society
Summary,
GUIDELINE OBJECTIVE(S)* To make recommendations for the use of antithrombotic and thrombolytic therapy in the management and treatment of ischemic stroke for the purpose of reducing mortality, disability, and complications of ischemic stroke
* To make recommendations for the use of antithrombotic therapy in the prevention of ischemic stroke
TARGET POPULATION
* Adults with or at risk of acute ischemic stroke
* Adults with cerebral venous sinus thrombosis
INTERVENTIONS AND PRACTICES CONSIDERED
Management/Treatment
Treatment of Acute Ischemic Stroke (AIS)
1. Thrombolytic therapy:
* Intravenous (IV) recombinant tissue plasminogen activator (tPA) with strict adherence to eligibility criteria for use
* In selected patients, intra-arterial thrombolytic therapy
2. Antithrombotic therapy:
* Anticoagulation in selected patients
* Early aspirin therapy
* Aspirin therapy in combination with low doses of subcutaneous heparin
Note: The following agents are considered but not recommended for the treatment of acute ischemic stroke: streptokinase (except within the confines of a clinical trial), full-dose anticoagulation, subcutaneous heparin and low-molecular-weight heparins or heparinoids.
Secondary Prevention of Deep Venous Thrombosis (DVT)/Pulmonary Embolism (PE) in Ischemic Stroke Patients
1. Low-dose subcutaneous heparin
2. Low-molecular-weight heparins
3. The heparinoid danaparoid
4. Nonpharmacologic measures:
* Intermittent pneumatic compression devices
* Elastic stockings
Prevention of Strokes
1. Aspirin therapy
2. Aspirin in combination with extended-release dipyridamole
3. Clopidogrel for patients allergic to aspirin
Note: Aspirin in combination with ticlopidine is considered, but not recommended.
Treatment of Cerebral Venous Sinus Thrombosis
1. Unfractionated heparin or low-molecular-weight heparin
2. Oral anticoagulation
Monitoring
1. International normalized ratio (INR)
2. Computed tomography (CT)
3. Magnetic resonance imaging (MRI)
MAJOR OUTCOMES CONSIDERED
Efficacy and safety of treatment, as defined by the following:
* Rates of mortality and disability from ischemic stroke
* Functional status
* Rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) secondary to ischemic stroke
* Rates of adverse events from treatment, such as intracerebral hemorrhages (ICH)
* Relative risk reduction of recurrent stroke and other vascular events (prevention)
