Voici des extraits de la m�ta-analyse de Cochrane qui m'apparaissent fort int�ressants. On consid�re l'anticoagulation aigu lorsqu'effectu�e dans les 2 SEMAINES de l'�pisode. Aucune cat�gorie de patients ne semble b�n�ficier du traitement. Certains passages mettent en doute la pertinence de l'anticoagulation prophylaxique pour la MTE dans ce contexte. Ceux qui sont int�ress�s � avoir le texte complet peuvent me le faire savoir (PDF de 437 kb).
"...Acute stroke treatments should aim to prevent disability as well as death, lest patients survive their acute stroke only to remain severely disabled. The present randomised evidence indicates that routine immediate anticoagulation does not provide any net short or long-term reduction in death or disability. Although immediate anticoagulation leads to fewer recurrent ischaemic strokes, avoiding nine ischaemic strokes per 1000 patients treated, this benefit is entirely offset by a similar-sized increase in the number of intracranial haemorrhages. The net result is no short- or long-term benefit..." "iii) Prevention of deep vein thrombosis and pulmonary embolism in acute ischaemic stroke. In patients with presumed or confirmed ischaemic stroke, allocation to immediate anticoagulation was associated with a highly significant 79% reduction in the odds of deep vein thrombosis during the treatment period, similar to that seen with the use of prophylactic heparin in patients undergoing different types of surgery (Collins et al 1988). In this systematic review, the reductions in deep vein thrombosis with acute anticoagulation were substantial, with 281 deep vein thromboses prevented per 1,000 patients treated. However, as mentioned previously, this estimate is based on relatively small numbers of patients, and most of the deep vein thromboses detected were asymptomatic. In addition, there was significant heterogeneity in the effects of treatment which was difficult to explain. If however, one accepts the estimate of treatment effect, it is then difficult to assess the extent to which it may be generalisable. The stroke patients included in the trials of anticoagulants to prevent deep vein thrombosis generally had quite severe strokes, and paralysis of one leg (with the attendant high risk of deep vein thrombosis) was almost invariably present at randomisation. Furthermore, with the widespread intorduction of Stroke Units, with policies of early mobilisation and good hydration, the risk of deep vein thrombosis may well be lower. In addition to deep vein thrombosis prevention, the risk of pulmonary embolism was also reduced significantly with the use of anticoagulants (OR 0.61; CI 0.45 - 0.83), with an additional four pulmonary emboli avoided per 1000 patients treated. The overall risk of pulomary embolism appeared to be low, and the absolute benefit was small, and so the apparent reduction in deep vein thrombosis may have little clinical relevance if there is not a correspondingly large reduction in pulmonary embolism. However, there may well have been under-ascertainment of pulmonary embolism in all of the trials, since pulmonary emboli were not sought systematically. In addition, deep vein thrombosis can lead to morbidity (eg. post-phlebitic leg and varicose ulcers), but data on these outcomes were not available from the trials. If anticoagulants result in no net increase or decrease in long-term death or disability, but do lead to a reduction in the number of deep vein thromboses and pulmonary emboli (albeit in immobile patients at higher risk), then the benefit of fixed heparin regimens associated with a low risk of bleeding (eg. low fixed-dose unfractionated heparin) may yet outweigh the increased risk of haemorrhage. Unfortunately, there were insufficient randomised data comparing low-dose heparin to aspirin, or to non-pharmacological interventions such as compression stockings or early mobilisation, to determine what the most effective and safe antithrombotic regimen for deep vein thrombosis prophylaxis might be. However, it is interesting to note from the IST (IST 1997) that the frequency of fatal and non-fatal symptomatic pulmonary embolism (perhaps a surrogate for the occurrence of deep vein thrombosis) was very similar among patients allocated low dose subcutaneous heparin alone (0.8%) and aspirin alone (0.7%). Aspirin alone may therefore be an adequate antithrombotic agent to be used for routine deep vein thrombosis prophylaxis in many patients with acute ischaemic stroke. There is substantial evidence to support the use of antiplatelets in deep vein thrombosis and pulmonary embolism prophylaxis in other categories of high-risk patients (APT 1994b). Finally, it is possible that once anticoagulants are stopped, rebound thrombosis could occur, and deep vein thromboses may begin to develop. We were unable to exclude this possibility because no trials sought deep vein thrombosis systematically after the treatment period. " v) Different categories of patient.. This systematic review provides information about the use of anticoagulants in stroke patients in general, as well as limited information about various subgroups. It is recognised that the evaluation of subgroups should only be undertaken with caution due to the increased potential for error due to the smaller numbers of patients and outcomes being evaluated. With that qualification in mind, the small amounts of (randomised) sub-group data evaluated here do not provide any evidence to support the routine use of anticoagulants in any specific category of stroke patient, including those with: cardioembolic stroke, 'stroke in progression', vertebrobasilar territory stroke, or following thrombolysis for acute ischaemic stroke to prevent re-thrombosis of the treated cerebral artery." MC ----- Original Message ----- From: "paulaye" <[EMAIL PROTECTED]> To: "URG-L Mailing List" <[EMAIL PROTECTED]> Sent: Monday, December 10, 2001 5:21 AM Subject: URG-L: RE: URG-L: Re: URG-L: RE: URG-L: FA et accident isch�mique c�r�bral. ATTENTION!!! Ne me faites pas dire ce que je n'ai pas dit. - Il faut faire le SCAN en urgence!!! - IL est FORMELLEMENT indiqu� d'administrer de l'HBPM SC � DOSES PREVENTIVES dans l'AVC isch�mique, ce en pr�vention de la maladie thromboembolique. La discussion portait sur l'anticoagulation curative Par ailleurs, il persiste de rares indications � l'anticoagulation th�rapeutique : 1- les porteurs de valve m�canique (relais des AVK) 2- 2 situations, o� m�me en l'absence de preuve certaine, il y a un fort consensus professionnel : la dissection carotidienne, et la thrombophl�bite c�r�brale (voir �tude de l'�quipe de Heidelberg)
