Original Article
Venous Thromboembolism in the Get With The Guidelines-Stroke Acute Ischemic Stroke Population: Incidence and Patterns of Prophylaxis

https://doi.org/10.1016/j.jstrokecerebrovasdis.2012.10.018Get rights and content

Background

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolus (PE), represents a serious complication in hospitalized ischemic stroke patients. This study examines the incidence of VTE and the patterns of VTE prophylaxis in acute ischemic stroke patients deemed appropriate for VTE prophylaxis (nonambulatory) in the Get With The Guidelines–Stroke (GWTG-S) study.

Methods

We analyzed data from 149,916 patients who were admitted with acute ischemic stroke and enrolled in GWTG-S from 1259 U.S. hospitals. Patient variables and site characteristics were analyzed in relation to reported administration of VTE prophylaxis.

Results

The overall rate of VTE prophylaxis in the analysis cohort was 93% (139,476/149,916). The median site prophylaxis rate was 95%, and prophylaxis rates ranged from 17% (1 site) to 100% (101 sites). Factors associated with increased likelihood of VTE prophylaxis in the multivariable model included history of atrial fibrillation/flutter, receipt of intravenous or intra-arterial tissue plasminogen activator, and admission to an academic hospital. Increasing age, black race, and a history of peripheral vascular disease, diabetes, or stroke were associated with lower likelihood of prophylaxis. Patients receiving care in the Midwest were less likely to receive prophylaxis compared to other regions.

Conclusions

Despite a high overall rate of VTE prophylaxis, VTE was found to occur in approximately 3% of GWTG-S patients. Reported rates of VTE prophylaxis differed among hospitals by region and hospital type, and among patients by age, race, and medical comorbidities.

Section snippets

Data

This is a retrospective evaluation of patient data entered prospectively into the Get With The Guidelines–Stroke (GWTG-S) registry. The GWTG-S program is an ongoing, prospective, observational database provided by the American Stroke Association/American Heart Association (ASA/AHA). Outcome Sciences, Inc is the data collection and coordination center for the GWTG-S program. Details of the design and quality control processes associated with the program have been described.3, 4 Data are entered

Results

Descriptive statistics for the 149,916 patients who met criteria for the analysis cohort are provided in Table 1. The median age of the patients was 75 years (25th-75th percentiles: 63-84). Just over half were women (55%), and the vast majority were white (71%). The median admission National Institutes of Health Stroke Scale (NIHSS) score was 8 (25th-75th percentiles: 3-15). The most common medical comorbidities were hypertension (82%), dyslipidemia (41%), and diabetes mellitus (34%).

Discussion

Stroke is known to be associated with an increased incidence of VTE. Published rates of clinically evident DVT and PE in the stroke population vary from a low of 0.2% to 10%6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 to a high of 15% to 80%.18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 As expected, the method used for VTE detection appears to dramatically influence the incidence rate; a 2004 study by Kelly et al18 reported an overall VTE incidence of 40% with the use of magnetic resonance imaging

References (43)

  • A. Sachdeva et al.

    Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines

    Am Heart J

    (2009)
  • L.H. Schwamm et al.

    Get With The Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack

    Circulation

    (2009)
  • Y. Xian et al.

    Data quality in the American Heart Association Get With The Guidelines-Stroke (GWTG-stroke): Results from a national data validation audit

    Am Heart J

    (2012)
  • W. Kehl-Pruett

    Deep vein thrombosis in hospitalized patients: A review of evidence-based guidelines for prevention

    Dimens Crit Care Nurs

    (2006)
  • M.D. Vergouwen et al.

    Venous thromboembolism prophylaxis and treatment in patients with acute stroke and traumatic brain injury

    Curr Opin Crit Care

    (2008)
  • C. Andre et al.

    Prevention of deep venous thrombosis and pulmonary embolism following stroke: A systematic review of published articles

    Eur J Neurol

    (2007)
  • R. Kay et al.

    Low-molecular-weight heparin for the treatment of acute ischemic stroke

    N Engl J Med

    (1995)
  • H. Kwiecinski et al.

    A randomized trial of fraxiparine in acute ischemic stroke

    Cerebrovasc Dis

    (1995)
  • The International Stroke Trial (IST): A randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke

    Lancet

    (1997)
  • Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: A randomized controlled trial

    JAMA

    (1998)
  • M. Hommel

    Fraxiparine in ischaemic stroke study

    Cerebrovasc Dis

    (1998)
  • Cited by (29)

    • Antithrombotic Therapy for Treatment of Acute Ischemic Stroke

      2021, Stroke: Pathophysiology, Diagnosis, and Management
    • Priority Nursing Interventions Caring for the Stroke Patient

      2020, Critical Care Nursing Clinics of North America
      Citation Excerpt :

      The prevalence of PE is 1% to 3%, which accounts for early death in the first 2 to 4 weeks after stroke onset.103 Risk factors for DVT in acute stroke are advanced age, female gender, high NIHSS score, hemiparesis, immobility, AFib, having received IV alteplase, and admission to an academic medical center. 104,105,106 However, immobility remains the highest contributor to the VTE risk.

    • Ambulatory Status Protects against Venous Thromboembolism in Acute Mild Ischemic Stroke Patients

      2016, Journal of Stroke and Cerebrovascular Diseases
      Citation Excerpt :

      They had a smaller sample size of 33 VTE events (1.3%) which could have been their limiting factor in identifying ambulation as a protective factor in a multivariable model. The VTE rate of 1%-3% may be underdiagnosed in the GWTGS database as it is dependent on the manual chart review.12,13 The DVT rate in ischemic stroke patients may vary from 1% to 18% depending on the screening methods, symptomatic or asymptomatic DVT, inclusion of transient ischemic attacks in study cohort, stroke severity, timing of DVT assessment, and use of chemical prophylaxis.4,14-16

    • Antithrombotic Therapy for Treatment of Acute Ischemic Stroke

      2015, Stroke: Pathophysiology, Diagnosis, and Management
    View all citing articles on Scopus

    The Get With The Guidelines–Stroke (GWTG-S) program is currently supported in part by a charitable contribution from Ortho-McNeil. GWTG-S has been funded in the past through support from Boeringher-Ingelheim, Merck, Bristol-Myers Squib/Sanofi Pharmaceutical Partnership, and the American Heart Association Pharmaceutical Roundtable. Sponsors did not participate in the design, analysis, manuscript preparation or approval for this project.

    View full text