Jay Shah, MD

Chung J-W, Kim BJ, Han M-K, Ko Y, Lee S, Kang K, et al. Impact of Guidelines on Clinical Practice: Intravenous Heparin Use for Acute Ischemic Stroke. Stroke. 2016

IV heparin has been available since the 1940’s and its role in ischemic stroke has been constantly debated. IV heparin has a clear indication in cardiac ischemia and many presume its efficacy should translate in acute ischemic stroke as well. However, numerous studies have failed to show benefit and American Stroke Association does not recommend anticoagulation acutely. Because heparin has been available for numerous years, there is little information on contemporary use and this study evaluated recent IV heparin trends across 12 hospitals in Korea in a 5 year span from 2008-2013.

Data was obtained from an acute stroke registry that included consecutive stroke patients. Information regarding stroke characteristics, recanalization treatment and antithrombotic treatment during hospitalization and post-discharge were collected. In total, 23,425 patients were included in the study. In the study period, the rate of recanalization treatment increased. Use of IV heparin decreased consecutively during the study period with use of 4.3% in 2013 compared to 9.7% initially. In the small proportion of patients that were treated with IV heparin, atrial fibrillation was associated with more frequent use.

This study shows declining rates of IV heparin use in acute ischemic stroke. This coincides with a 2009 publication of a Korean stroke clinical practice guideline and supports adherence to guidelines by neurologist. Interestingly, atrial fibrillation was associated with use of IV heparin. Typically, cardioembolic strokes are generally larger and acute anticoagulation is not pursued due to hemorrhage risk. Furthermore, subsequent short-term stroke risk following a cardioembolic stroke is relatively lower (unlike large vessel disease) and delaying anticoagulation until hemorrhage risk is lower has become the standard practice. Use of IV heparin is sometimes reserved for patients with critical carotid stenosis awaiting carotid endarterectomy but such decisions are made on case-by-case basis. This study further affirms that clinical guideline recommendations impact clinical decision making and have the ability to impact outcomes as well.