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To the Editor:
In a review on IV heparin for acute stroke, Swanson concludes that “… routine administration of IV heparin to acute stroke patients is likely to do more harm than good and suggests that this practice should be discontinued until better evidence . …”1 To reach this conclusion, Dr. Swanson’s review is mostly based on the low-recurrence stroke rates shown in recent megatrials. If low recurrence is the argument used against acute anticoagulation (ATC), a few things should be considered.
TOAST, a study with a high proportion of strokes of undetermined etiology and lack of treatment benefit in patients with cardioembolic events, reported a significant morbidity and mortality associated with recurrence. For reasons discussed elsewhere (particularly the inclusion of patients in centers without experience in stroke diagnosis), IST results are probably biased to provide meaningful conclusions on recurrence.2 Among other studies, Moroney et al. reported a 7.4% recurrence rate within 3 months in 300 patients with acute stroke.3 Most recurrences were early (first month), associated with high mortality (32%) and predicted by large-vessel disease (not just cardioembolism). Different studies have consistently shown that cardioembolic stroke recurrence is not only high but that it tends to occur within the first month with half of the emboli reaching the brain.4 Surprisingly, Dr. Swanson also believes that treatment of cardiogenic emboli with heparin “may warrant reassessment in light of the IST findings… .”
Another issue invoked is the risk …
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