Banning anticoagulation in stroke or consequence of poor study design.

Abstract

To the Editor: We read with great interest the review from H.P. Adams1 who critically re-evaluates individual aspects of well-known and often-discussed studies on anticoagulation in acute stroke. These studies do not exhibit a net benefit of anticoagulant use with regard to the criteria safety, mortality, morbidity, prevention of stroke recurrence and late outcome. The author emphasized the differences among the individual studies with regard to sample sizes, time-to-start of therapy (extending up to 48 hours after stroke onset), protocols for dosages and controls of anticoagulants used and the route of administration leading to a distinct criticism of major meta-analysis published. In addition, prominent shortcomings such as the missing baseline brain imaging studies in the dominating IST and CAST trials and the lack of any efforts to differentiate among stroke subtypes with gross under representation of embolic mechanisms are mentioned. However, despite these shortcomings, H.P. Adams concludes that he sees no indication for anticoagulation in acute stroke and suggests the future role of anticoagulants will be very limited. In our view this conclusion is premature and not accepted by many “stroke experts” in institutions where advanced diagnostic techniques and neuro-monitoring are available. So far the albeit limited data available from these trials reveals statistically significant advantages of anticoagulation in the prevention of deep venous thrombosis, pulmonary …