Use of aspirin and heparin for treatment of stroke in a community hospital emergency department in the 21st century

Abstract

Study objectives: Stroke is the third leading cause of death in the United States and the leading cause of adult disability. The International Stroke Trial and Chinese Acute Stroke Trial demonstrated decreases in mortality, disability, and recurrent stroke for patients who received early administration of aspirin. A systematic review by the Cochrane Collaboration and the Heparin in Acute Embolic Stroke Trial (HAEST) study, both published in early 2000, found no benefit from heparin in the management of any subgroup of acute stroke patients. No study has been published that surveys the frequency of aspirin and heparin use in the early management of acute stroke in a community emergency department (ED). One study published a survey of frequency of heparin and aspirin administration during a hospitalization for acute stroke and found a 10% and 44% rate, respectively. Our study characterizes the frequency of aspirin and heparin use by emergency physicians in managing strokes in the 21st century to discover whether the recent evidence supporting aspirin and discouraging heparin use has affected practice. We determine the use of aspirin and heparin for treatment of acute stroke in an urban community ED in 2000 to 2001. Methods: We performed a retrospective chart review for aspirin and heparin use in patients with a primary ED diagnosis of cerebrovascular accident from January 2000 to May 2001. Review methodology previously recommended was implemented and included a single chart reviewer who used a standardized abstraction form. Additionally, a second reviewer reabstracted a sample of charts to measure interpreter reliability. Computerized order-entry records and physician dictations were reviewed to quantify the rate of aspirin and heparin use, as well as the frequency of aspirin contraindications (allergic reactions, previous antiplatelet use on day of treatment, active bleeding). Results: Five hundred eighty-five patients were diagnosed with acute cerebrovascular accident during the 17-month study period. Two hundred fifty-one patients received aspirin, which represented 43% (95% confidence interval [CI] 39% to 47%) of patients who were candidates for aspirin therapy. Fifty-nine patients (10%; 95% CI 8% to 12%) received heparin. Conclusion: We found that aspirin is underused and heparin is overused in the early management of acute stroke in a community ED in the 21st century. Efforts should be made to increase awareness of the beneficial effects of aspirin and nonbeneficial effects of heparin in the early treatment of stroke patients.