Sandercock Peter Ag, Leong Tze Shin
Centre for Clinical Brain Sciences (CCBS), University of Edinburgh, The Chancellor's Building, 49 Little France Crescent, Edinburgh, UK, EH16 4SB.
University of Edinburgh, Edinburgh, UK.
Cochrane Database Syst Rev. 2017 Apr 4;4(4):CD000119. doi: 10.1002/14651858.CD000119.pub4.
Low-molecular-weight heparins (LMWHs) and heparinoids are anticoagulants that may have more powerful antithrombotic effects than standard unfractionated heparin (UFH) but a lower risk of bleeding complications. This is an update of the original Cochrane Review of these agents, first published in 2001 and last updated in 2008.
To determine whether antithrombotic therapy with LMWHs or heparinoids is associated with a reduction in the proportion of people who are dead or dependent for activities in daily living compared with UFH.
We searched the Cochrane Stroke Group Trials Register (last searched February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library Issue 1, 2017), MEDLINE (1966 to February 2017), and Embase (1980 to February 2017). We also searched trials registers to February 2017: ClinicalTrials.gov, EU Clinical Trials Register, Stroke Trials Registry, ISRCTN Registry and the World Health Organization (WHO) International Clinical Trials Registry Platform.
Unconfounded randomised trials comparing LMWH or heparinoids with standard UFH in people with acute ischaemic stroke, in which participants were recruited within 14 days of stroke onset.
Two review authors independently chose studies for inclusion, assessed risk of bias and trial quality, extracted and analysed the data. Differences were resolved by discussion.
We included nine trials involving 3137 participants. We did not identify any new trials for inclusion in this updated review. None of the studies reported data on the primary outcome in sufficient detail to enable analysis for the review. Overall, there was a moderate risk of bias in the included studies. Compared with UFH, there was no evidence of an effect of LMWH or heparinoids on death from all causes during the treatment period (96/1616 allocated LMWH/heparinoid versus 78/1486 allocated UFH; odds ratio (OR) 1.06, 95% CI 0.78 to 1.47; 8 trials, 3102 participants, low quality evidence). LMWH or heparinoid were associated with a significant reduction in deep vein thrombosis (DVT) compared with UFH (OR 0.55, 95% CI 0.44 to 0.70, 7 trials, 2585 participants, low quality evidence). However, the number of the major clinical events such as pulmonary embolism (PE) and intracranial haemorrhage was too small to provide a reliable estimate of the effects.
AUTHORS' CONCLUSIONS: Treatment with a LMWH or heparinoid after acute ischaemic stroke appears to decrease the occurrence of DVT compared with standard UFH, but there are too few data to provide reliable information on their effects on other important outcomes, including functional outcome, death and intracranial haemorrhage.
低分子量肝素（LMWHs）和类肝素是抗凝剂，它们可能比标准普通肝素（UFH）具有更强的抗血栓形成作用，但出血并发症风险较低。这是对这些药物最初的Cochrane系统评价的更新，该评价首次发表于2001年，上次更新于2008年。
确定与普通肝素相比，使用低分子量肝素或类肝素进行抗血栓治疗是否能降低死亡或日常生活活动依赖者的比例。
我们检索了Cochrane卒中小组试验注册库（最后检索时间为2017年2月）、Cochrane对照试验中央注册库（CENTRAL：Cochrane图书馆2017年第1期）、MEDLINE（1966年至2017年2月）和Embase（1980年至2017年2月）。我们还检索了截至2017年2月的试验注册库：ClinicalTrials.gov、欧盟临床试验注册库、卒中试验注册库、ISRCTN注册库和世界卫生组织（WHO）国际临床试验注册平台。
在急性缺血性卒中患者中，比较低分子量肝素或类肝素与标准普通肝素的非混淆随机试验，其中参与者在卒中发作后14天内入组。
两位综述作者独立选择纳入研究，评估偏倚风险和试验质量，提取并分析数据。通过讨论解决分歧。
我们纳入了9项试验，涉及3137名参与者。我们未识别出任何新的试验可纳入本次更新的综述。没有一项研究足够详细地报告主要结局的数据以进行综述分析。总体而言，纳入研究存在中度偏倚风险。与普通肝素相比，没有证据表明低分子量肝素或类肝素在治疗期间对全因死亡有影响（1616名分配使用低分子量肝素/类肝素者中有96人死亡，1486名分配使用普通肝素者中有78人死亡；比值比（OR）为1.06，95%置信区间为0.78至1.47；8项试验，3102名参与者，低质量证据）。与普通肝素相比，低分子量肝素或类肝素与深静脉血栓形成（DVT）的显著减少相关（OR为0.55，95%置信区间为0.44至0.70，7项试验，2585名参与者，低质量证据）。然而，肺栓塞（PE）和颅内出血等主要临床事件的数量太少，无法提供可靠的效应估计。
与标准普通肝素相比，急性缺血性卒中后使用低分子量肝素或类肝素治疗似乎可降低深静脉血栓形成的发生率，但数据太少，无法提供关于它们对其他重要结局（包括功能结局、死亡和颅内出血）影响的可靠信息。
