What is the clinical evidence from this study?

Study design: Observational. Population: Acute ischemic stroke (n=1524). Intervention: Thromboprophylaxis vs. No thromboprophylaxis. Primary outcome: Symptomatic DVT/PE events during index hospitalization and up to 30 days post-discharge.

February 8, 2013Open Access

Rate of deep-vein thrombosis and pulmonary embolism during the care continuum in patients with acute ischemic stroke in the United States

AAAlpesh AminHeart Failure / Cardiomyopathy JLJay LinChinese University of Hong Kong STStephen ThompsonSchool of Advanced Study

Key Result

Symptomatic deep-vein thrombosis or pulmonary embolism occurred in 1.64% of patients with acute ischemic stroke, with only 46.1% receiving in-hospital and 6.4% receiving outpatient thromboprophylaxis.

Study Design

Type

Observational (n=1,524)

Multicenter

Yes

Structured PICO

Population

1,524 adult patients hospitalized for acute ischemic stroke in the US, excluding those with atrial fibrillation, evaluated for DVT/PE rates and prophylaxis use up to 30 days post-discharge.

Exposure

Pharmacological (unfractionated heparin, enoxaparin, warfarin) and/or mechanical thromboprophylaxis during index hospitalization and up to 14 days post-discharge

Outcome

Rate of symptomatic deep-vein thrombosis (DVT) and pulmonary embolism (PE) during index hospitalization and up to 30 days post-dischargehard clinical

Despite a 1.64% rate of symptomatic DVT/PE across the care continuum in acute ischemic stroke patients, outpatient thromboprophylaxis is vastly underutilized compared to inpatient prophylaxis.

Limitations

The database may not be representative of the US ischemic stroke population as a whole with regards to patient age and length of hospitalization.
The level of reduced mobility in patients could not be evaluated, limiting the assessment of actual DVT/PE risk and the appropriateness of prophylaxis.
Outpatient use of mechanical prophylaxis was not captured due to over-the-counter availability.
The rate of readmission for DVT/PE could be underestimated if patients were readmitted to a hospital that is not included in the database.

Abstract

BACKGROUND: Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are frequent and life-threatening complications of ischemic stroke. We evaluated rates of symptomatic DVT/PE, and of in-hospital and post-discharge thromboprophylaxis in patients with acute ischemic stroke (AIS). METHODS: In a retrospective US database analysis, data were extracted from the Premier Perspective™-i3 Pharma Informatics linked database for patients aged ≥18 years who were hospitalized for ischemic stroke from January 2005 to November 2007, and who had ≥6 months' continuous plan enrollment prior to index hospitalization. Patients discharged to an acute-care facility or with atrial fibrillation were excluded. Prophylaxis was evaluated during index hospitalization and for 14 days' post-discharge. DVT/PE rates were calculated during index hospitalization and up to 30 days post-discharge. RESULTS: A total of 1524 patients were included; 46.1% received pharmacological and/or mechanical prophylaxis in-hospital (28.3%, 11.4% and 12.3% received unfractionated heparin, enoxaparin and mechanical prophylaxis, respectively). 6.4% of patients received outpatient pharmacological prophylaxis; warfarin was most frequently prescribed (5.9%). Total mean ± standard deviation length of index hospitalization was 3.0 ± 2.5 days. Mean prophylaxis duration in all patients was 0.9 ± 1.5 days in-hospital and 1.7 ± 6.9 days post-discharge. Symptomatic DVT/PE occurred in 25 patients overall (1.64%), with an inpatient rate of 0.98% and an outpatient rate of 0.66%. CONCLUSIONS: Approximately 1% of patients with AIS experienced symptomatic in-hospital and/or post-discharge DVT/PE. Although 46% received prophylaxis in-hospital, only 6% received prophylaxis in the outpatient setting. This highlights the need for sustained thromboprophylaxis prescribing across the continuum of care.

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