Low Molecular-Weight Heparin Improves the Length of Post-Stroke Hospital Days
Abstract & Commentary
Source: Kalafut MA, et al. Safety and cost of low-molecular-weight heparin as bridging anticoagulant therapy in subacute cerebral ischemia. Stroke 2000;31:2563-2568.
Kalafut and associates at the ucla stroke Center summarize the safety and cost-effectiveness of delivering subcutaneous low-molecular-weight heparin (LMWH), compared to intravenous unfractionated heparin (IVUH) against acute stroke. The rationale of either procedure consists of protecting against both extending thrombosis in the already injured cerebral ischemic areas or the prevention of deep vein thrombosis during the early post-stroke hours of potential immobility.
The practice of the previous 24 consecutive patients on the IVUH protocol had been to start continuous IVUH on hospital day 1.3 and warfarin on 2.1 days. Some of the group had to extend appropriate chronic anticoagulation for 5-9 days after onset because of patients’ sluggish development in attaining appropriate INRs. Kalafut et al have followed a similar protocol but have substituted LMWH in place of IVUH. There are several particular cited advantages of this practice. LMWH has a long half-life effectiveness and can be given subcutaneously at doses of 1 mg/kg either once or twice daily. Also, it avoids heparin-induced thrombocytopenia, does not need regular blood testing for measuring anticoagulation, and spares patients the risks of clumsiness and movement limitations that accompany infusion poles and bottles that clumsily carry heparin all day.
Kalafut et al compare the outcomes of the two succeeding groups of 24 persons undergoing acute strokes but followed the second UCLA stroke protocol using LMWH and not IVUH. Age, gender, and other similar variables were not significantly different except for five of the LMWH patients who received tPA without complication and used more thrombolytic treatment. During the early hospital days, two LMWH patients had neurological worsening compared with eight who worsened among the IVUH group (P < 0.05). The IVUH cohort also developed bloody stools (5), gross hematuria (3), phlebitis (2), and thrombocytopenia (2). The LMWH cohort experienced none of those complications. Infarct size did not differ significantly between the two groups. Among the IVUH patients, two-thirds had their hospital stays extended an average of 2-4 days to complete IVUH transferring to oral warfarin. Costs for physical and occupational therapy initiated during hospitalization were longer and more costly in the IVUH group, largely because of the clumsiness of 24-hour intravenous lines.
Across the IVUH cohort, cost of bridging anticoagulation was $53,541, with a mean of $2231 per patient. Across the entire LMWH cohort cost was $51,136.
When all patients were capable to return home or to a rehab facility, the average patient in the LMWH group produced a net cost savings of $865.
Commentary
Kalafut et al have provided a possibly favorable approach to the early treatment of acute stroke using the LMWH anticoagulants. They may be expensive compared to IVUH, but their fewer complications, lesser variability, smaller nursing costs, and their safe "get home quicker" capacity save more money without creating hazards.
An additional value of the approach not noted in this article is that it encourages patients to get out of bed, to move about as much as possible, and to be immediately approached by rehabilitation. It’s time that the American Academy of Neurology and the American Neurological Association approach the insurance companies to recognize that home rehabilitation would save them a lot of money and bring more cheer than is now spent on hospital therapies. —Fred Plum
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