Safety and Cost of Low-Molecular-Weight Heparin as Bridging Anticoagulant Therapy in Subacute Cerebral Ischemia

BACKGROUND AND PURPOSE: Anticoagulation with intravenous unfractionated heparin (IVUH) while awaiting therapeutic oral anticoagulant levels is a common practice in patients with acute and subacute cerebral ischemia. A promising alternative strategy is to use bridging subcutaneous low-molecular-weight heparin (LMWH), which may have a favorable risk-benefit profile compared with IVUH and may permit earlier discharge with completion of transition to warfarin therapy as an outpatient. METHODS: A LMWH, enoxaparin 1 mg/kg BID, was used as bridging anticoagulation therapy in 24 consecutive patients admitted to a university stroke center in whom the treatment plan included transition from acute to chronic anticoagulation. The LMWH group was contrasted with the preceding 24 patients transitioned to warfarin with IVUH at the same center. RESULTS: Fewer patients in the LMWH bridging therapy group experienced neurological worsening than in the IVUH bridging therapy group (2/24 versus 8/24; P:=0.033). Fewer total adverse events were noted in the LMWH group than in the IVUH cohort (3 versus 20; P:=0. 002). Fifteen of the 24 LMWH patients (62.5%) were discharged while still receiving LMWH and completed transition to warfarin as outpatients, receiving an average of 3.6 days of outpatient transitional therapy. In these 15 patients, use of LMWH was associated with a net savings of $2197 per patient. CONCLUSIONS: In this pilot cohort with subacute cerebral ischemia, bridging LMWH appeared to be safer than bridging IVUH and was associated with reduced hospital stay and reduced total cost of care.