Use of Heparin in Acute Ischemic Stroke: Is There Still a Role?

Abstract

Heparin has long been a contested therapy in acute ischemic stroke (AIS). In current practice, heparin is considered on a case-by-case basis, but there is no consensus as to the appropriate timing of anticoagulation or for which ischemic stroke subtypes heparin may be beneficial. To provide better clarity on this issue, we review current research focusing on the use of heparin in AIS in each stroke subtype and subsequently make recommendations to provide readers with a systematic approach to managing complex stroke patients for which acute anticoagulation may be valuable. We conclude that there are certain subpopulations of ischemic stroke patients that may derive benefit from heparin when given acutely, including patients with symptomatic large artery stenosis >70 %, non-occlusive intraluminal thrombus, and in patients with high-risk cardiac conditions including left ventricular thrombus, left ventricular assist devices, and mechanical heart valves.

Factors influencing the efficacy of recombinant tissue plasminogen activator: Implications for ischemic stroke treatment

“…Combining rt-PA with heparin could be a valuable clinical concept [ 16 , 17 ] but our data do not confirm the positive effect of heparin on rt-PA enzymatic action if applied at clinically relevant concentration. Such observation is contradictory to some early studies, which indicated that heparin could activate rt-PA at concentrations up to 50 IU/ml.…”

Factors influencing the efficacy of recombinant tissue plasminogen activator: Implications for ischemic stroke treatment

“…Combining rt-PA with heparin could be a valuable clinical concept [ 16 , 17 ] but our data do not confirm the positive effect of heparin on rt-PA enzymatic action if applied at clinically relevant concentration. Such observation is contradictory to some early studies, which indicated that heparin could activate rt-PA at concentrations up to 50 IU/ml.…”

Triple Therapy: A Safe Inexpensive Regimen of Heparin, Aspirin, and Clopidogrel for Intracranial Vessel Occlusions in Acute Ischemic Stroke Patients Ineligible for Intravenous Thrombolytics and Endovascular Thrombectomy

“…Nonetheless, anticoagulation continues to play a role in the management of select ischemic stroke patients, including those with symptomatic large artery stenosis >70%, non-occlusive intraluminal thrombus, high-risk cardiac conditions such as left ventricular thrombus or mechanical heart valves, intracranial atherosclerotic disease with suspected thrombus, arterial dissection, and extracranial large vessel disease. 11 In these cases, the potential to reduce stroke burden by preventing early recurrent events, halting infarct progression, and improving collateral circulation outweighs the risk of hemorrhage, thus making anticoagulation a recommended strategy. We propose that another select subgroup of patients — those presenting with large or medium intracranial vessel occlusion and minor neurological deficits who are ineligible for intravenous thrombolysis and unable to undergo thrombectomy — may similarly benefit from transient anticoagulation.…”

Long‐term risk of stroke and its predictors in transient ischaemic attack patients in Germany

“…apixaban, dabigatran, edoxaban, rivaroxaban), a recent network meta‐analysis showed that these molecules were associated with a substantial decrease in the risk of stroke in patients with atrial fibrillation . Heparins are anticoagulant drugs and, although their use in the context of acute ischaemic stroke has been debated, previous research has suggested that these molecules can be used in certain subpopulations of individuals with ischaemic stroke, such as those with symptomatic large artery stenosis >70%, those with non‐occlusive intraluminal thrombus and those with high‐risk cardiac conditions . Furthermore, the prescription of diuretics and angiotensin II receptor blockers, two families of drugs with antihypertensive effects, may be of particular interest for the prevention of ischaemic stroke .…”

Factors influencing the efficacy of recombinant tissue plasminogen activator: Implications for ischemic stroke treatment

“…Combining rt-PA with heparin could be a valuable clinical concept [ 16 , 17 ] but our data do not confirm the positive effect of heparin on rt-PA enzymatic action if applied at clinically relevant concentration. Such observation is contradictory to some early studies, which indicated that heparin could activate rt-PA at concentrations up to 50 IU/ml.…”

Triple Therapy: A Safe Inexpensive Regimen of Heparin, Aspirin, and Clopidogrel for Intracranial Vessel Occlusions in Acute Ischemic Stroke Patients Ineligible for Intravenous Thrombolytics and Endovascular Thrombectomy

“…Nonetheless, anticoagulation continues to play a role in the management of select ischemic stroke patients, including those with symptomatic large artery stenosis >70%, non-occlusive intraluminal thrombus, high-risk cardiac conditions such as left ventricular thrombus or mechanical heart valves, intracranial atherosclerotic disease with suspected thrombus, arterial dissection, and extracranial large vessel disease. 11 In these cases, the potential to reduce stroke burden by preventing early recurrent events, halting infarct progression, and improving collateral circulation outweighs the risk of hemorrhage, thus making anticoagulation a recommended strategy. We propose that another select subgroup of patients — those presenting with large or medium intracranial vessel occlusion and minor neurological deficits who are ineligible for intravenous thrombolysis and unable to undergo thrombectomy — may similarly benefit from transient anticoagulation.…”

Long‐term risk of stroke and its predictors in transient ischaemic attack patients in Germany

“…apixaban, dabigatran, edoxaban, rivaroxaban), a recent network meta‐analysis showed that these molecules were associated with a substantial decrease in the risk of stroke in patients with atrial fibrillation . Heparins are anticoagulant drugs and, although their use in the context of acute ischaemic stroke has been debated, previous research has suggested that these molecules can be used in certain subpopulations of individuals with ischaemic stroke, such as those with symptomatic large artery stenosis >70%, those with non‐occlusive intraluminal thrombus and those with high‐risk cardiac conditions . Furthermore, the prescription of diuretics and angiotensin II receptor blockers, two families of drugs with antihypertensive effects, may be of particular interest for the prevention of ischaemic stroke .…”

Factors influencing the efficacy of recombinant tissue plasminogen activator: Implications for ischemic stroke treatment

“…Combining rt-PA with heparin could be a valuable clinical concept [ 16 , 17 ] but our data do not confirm the positive effect of heparin on rt-PA enzymatic action if applied at clinically relevant concentration. Such observation is contradictory to some early studies, which indicated that heparin could activate rt-PA at concentrations up to 50 IU/ml.…”

Triple Therapy: A Safe Inexpensive Regimen of Heparin, Aspirin, and Clopidogrel for Intracranial Vessel Occlusions in Acute Ischemic Stroke Patients Ineligible for Intravenous Thrombolytics and Endovascular Thrombectomy

“…Nonetheless, anticoagulation continues to play a role in the management of select ischemic stroke patients, including those with symptomatic large artery stenosis >70%, non-occlusive intraluminal thrombus, high-risk cardiac conditions such as left ventricular thrombus or mechanical heart valves, intracranial atherosclerotic disease with suspected thrombus, arterial dissection, and extracranial large vessel disease. 11 In these cases, the potential to reduce stroke burden by preventing early recurrent events, halting infarct progression, and improving collateral circulation outweighs the risk of hemorrhage, thus making anticoagulation a recommended strategy. We propose that another select subgroup of patients — those presenting with large or medium intracranial vessel occlusion and minor neurological deficits who are ineligible for intravenous thrombolysis and unable to undergo thrombectomy — may similarly benefit from transient anticoagulation.…”

Long‐term risk of stroke and its predictors in transient ischaemic attack patients in Germany

“…apixaban, dabigatran, edoxaban, rivaroxaban), a recent network meta‐analysis showed that these molecules were associated with a substantial decrease in the risk of stroke in patients with atrial fibrillation . Heparins are anticoagulant drugs and, although their use in the context of acute ischaemic stroke has been debated, previous research has suggested that these molecules can be used in certain subpopulations of individuals with ischaemic stroke, such as those with symptomatic large artery stenosis >70%, those with non‐occlusive intraluminal thrombus and those with high‐risk cardiac conditions . Furthermore, the prescription of diuretics and angiotensin II receptor blockers, two families of drugs with antihypertensive effects, may be of particular interest for the prevention of ischaemic stroke .…”