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Post-stroke VTE prophylaxis – are compressive stockings redundant?

Discontinuing compressive stockings for standard care in all UK stroke units did not increase venous thromboembolism incidence in routine clinical practice, according to a study1 published recently in Stroke.

Authors identified all stroke register entries at the University Hospital of North Staffordshire from two years before and two years after the publication of the Clots in Legs Or sTockings after Stroke (CLOTS) trial results, which concluded that stockings were ineffective. The hospital radiology reporting system was then cross-checked for evidence of venous thromboembolism on computed tomography pulmonary angiogram, ventilation/perfusion lung scan, and leg Doppler reports.

There were 773 patients in the before cohort and 861 in the after cohort (mean age, 74/74 years; men, 47%/45%; and ischemic stroke, 87%/85%, respectively). Symptomatic venous thromboembolism incidence was the same in both cohorts, 21 (2.7%) in the before cohort and 26 (3.0%) in the after cohort (P=0.8). There was a trend toward more deep vein thrombosis (9 [1.2%] versus 19 [2.2%]; P=0.1) and fewer pulmonary embolisms (12 [1.6%] versus 6 [0.7%]; P=0.2) in the after cohort.

Professor Christine Roffe (Keele University, UK)

Professor Christine Roffe (Keele University, UK)

There was a trend toward more deep vein thrombosis and fewer pulmonary embolisms (PEs) after the CLOTS publication, the authors said. This might be due to increased clinical vigilance in the diagnosis of deep vein thrombosis, but a chance variation cannot be excluded, they concluded.

Speaking to BJC Arrhythmia Watch, co-author Professor Christine Roffe (Keele University, UK) said: “CLOTS I and II have shown that neither full length nor knee length stockings are effective in preventing DVT and PE after stroke, but that they have side effects such as skin damage and discomfort. Therefore TED stockings should not be used for prevention of thromboembolism after stroke. As neither patients nor staff liked the stockings much, and, of course, not using stockings saves money, the change in practice was immediate and comprehensive. Most UK stroke units had taken part in the study, and the news that stockings did not work spread rapidly via all the collaborating centres.”

“There is good evidence that stockings prevent thrombosis after surgery,” she continued. “In these patients the stockings are put on before they are immobilised by the operation, e.g. before there is a chance for the thrombosis to develop. There is considerably less evidence in medical patients. NICE recommends the use of anti-embolism stockings in medical patients at high risk of thromboembolism who have contraindications to prophylactic anticoagulation.”

“As far as I am aware there is no research evidence for or against use of anti-embolic stockings on long-haul flights other than that it might be a good idea, as there is increased risk of thromboembolism, and similar to surgical patients stockings can be placed before the start of the immobilization,” she added.

On the use of drug treatment as an alternative to compression devices after stroke, Professor Roffe said: “The results of the CLOTS-3 study clearly show that intermittent pneumatic compression with sleeves applied to the legs significantly reduces DVT and there was also a (non-significant) reduction in mortality at 90 days. The IST Study has shown in the 1990s that aspirin reduces the risk of DVT and improves outcome after acute stroke. It should therefore be used in all ischaemic stroke patients who have no contraindications.”

“For longer-term prophylaxis aspirin has been replaced by clopidogrel. IST has also shown that prophylactic anticoagulation reduces DVT after stroke, but has no impact on death or disability after three months, with prevention of thromboembolism being counterbalanced by an increase of haemorrhages. A recent metaanalysis of studies of pharmacologic prevention of thromboembolism after stroke including unfractionated heparin as well and the newer low molecular heparins and heparioids showed that prevention of symptomatic pulmonary emboli was balanced by an increase in intracerebral haemorrhages,” she added.

“In spite of this and the RCP stroke guidance suggesting that anticoagulation should be used routinely after stroke, prophylactic anticoagulation is widely used in UK stroke units. Unlike the results of CLOTs-1 which were acted upon more or less immediately the change in practice following the CLOTs-3 results has not been as dramatic. A potential reason for this is the need to purchase the pumps and sleeves,” Professor Roffe said.

“Antihypertensive treatment after stroke is important for secondary prevention. The target bold pressure has been reduced from 140/85 to 130/80 in the latest UK stroke guidelines (RCP 2012). Antihypertensive treatment is not used as a preventative measure for thromboembolism,” she concluded.

References

1. Jain P, IB Ward E, Nevatte T, Roffe C. Incidence of venous thromboembolism in the wake of the Clots in Legs Or sTockings after Stroke (CLOTS) study. Stroke 2013. http://dx.doi.org/10.1161/​STROKEAHA.113.001458

Published on: August 30, 2013

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