Stockings for stroke patients don't work
By MARIA CHENG
The Associated Press
Wednesday, May 27, 2009; 6:23 AM
LONDON -- Special stockings commonly given to stroke patients to prevent blood clots don't work, a new study reported Wednesday.
Doctors often prescribe the tight, thigh-high stockings to patients who have suffered a stroke, seeking to prevent blood clots in patients' legs _ which could prove fatal if they break off and reach the heart or lungs.
About two-thirds of stroke patients can't walk when admitted to hospital, and up to 20 percent of those patients develop a blood clot in their legs. The stockings squash the legs and force the blood to circulate better, and can be used in place of, or alongside, anti-clotting drugs like heparin.
But in a study of more than 2,500 stroke patients in Australia, Britain and Italy, doctors found the stockings did nothing to reduce the chances of a clot. Not only that, but they caused problems like skin ulcers and blisters.
The results were simultaneously published in the Lancet medical journal and presented at the European Stroke Conference in Stockholm on Wednesday.
Some experts were surprised by the findings.
"We have used these stockings because we assume they work," said Dr. Ralph Sacco, president-elect of the American Heart Association, who was not linked to the study. "But sometimes you're surprised when you find out the truth with a randomized trial."
The stockings have been proven to reduce clots in surgery patients, so experts had long thought the low-cost solution might also help stroke patients.
In the study, about half of the patients got standard care in addition to the stockings. The other half just got standard care. Experts took an ultrasound of patients' legs after about 7 to 10 days, and then again after 25 to 30 days. About 10 percent of patients in both groups developed blood clots.
In the group wearing stockings, 5 percent reported side effects like skin problems and blisters. That compares to 1 percent in the group not given the stockings.
The study was paid for by Britain's Medical Research Council, the Scottish government, the health charity Heart and Stroke Scotland, Tyco Healthcare in the United States and the U.K. Stroke Research Network.
In Britain, draft guidelines recommend patients wear the stockings and they are used to treat an estimated 80,000 patients per year. Martin Dennis, of the University of Edinburgh and one of the study authors, said he has contacted British officials to suggest they reconsider their advice.
"This should cause a big change in how patients are treated," Dennis said, noting that in 2002, 90 percent of stroke units in Britain used the stockings.
In the United States, stockings for stroke patients are far less popular than in the U.K.
Dr. Marc Mayberg, co-director of the Seattle Neuroscience Institute, said he hadn't recommended the stockings for patients in about 20 years. He said the stockings were cumbersome and difficult for many patients, whose legs were paralyzed, to put on and take off.
Recommendations from the American Heart Association published in 2005 advised doctors to consider using the stockings in addition to an anti-clotting drug, or for patients who can't take such drugs.
Sacco said American doctors were more likely to use drugs instead of stockings to prevent clots. He thought the guidelines promoting stockings might now have to be revised.
"With this lack of effect, doctors may be much less inclined to use them," he said.
Page last updated at 14:29 GMT, Wednesday, 27 May 2009 15:29 UK
Stockings 'no stroke clot help'
Compression stockings are designed to increase blood clot in the legs
Surgical stockings do not cut stroke patients' risk of developing blood clots, research suggests.
Doctors commonly use the stockings as way to minimise the risk of clots forming and travelling to the lungs or heart, where they can be fatal.
But a Lancet study, by the University of Edinburgh, found they had little positive effect.
The team estimates cutting stocking use could save the NHS around £7m and 320,000 hours of nursing time a year.
Abandoning this ineffective and sometimes uncomfortable treatment will free up valuable resources in our health services
Professor Martin Dennis
University of Edinburgh
It was previously thought the tight stockings helped to increase blood flow through the legs and reduce the formation of clots.
Around two thirds of stroke patients are unable to walk on admission to hospital and approximately 15% develop blood clots because of this lack of movement.
The Edinburgh team studied over 2,500 stroke patients in the UK, Italy and Australia.
All received routine care, including aspirin and assisted exercise, and half were offered surgical stockings as well.
After 30 days there was no significant difference in the blood clot rate in the two groups.
However, the group given stockings experienced more skin breaks, ulcers and blisters than those without.
Compression stockings are still recommended for patients who have undergone surgery and for people travelling on long-haul flights.
Call for new guidelines
Researcher Professor Martin Dennis said: "The guidelines on the use of these stockings have been based on evidence collected in surgical patients and not in stroke patients.
"We have shown conclusively that compression stockings do not work for stroke patients.
"The national guidelines need to be revised and we need further research to establish effective treatments for these patients.
"Abandoning this ineffective and sometimes uncomfortable treatment will free up valuable resources in our health services."
Dr Peter Coleman, of the Stroke Association, said: "It is important that all treatments are carefully evaluated, and if studies show they are ineffective in stroke patients, we believe they should be discontinued.
"It is still vital, however, that patients are carefully monitored after their stroke to ensure there are no further complications, and to ensure they receive the best possible treatment."
More than 150,000 people a year have a stroke in the UK.
The Lancet, Early Online Publication, 27 May 2009
doi:10.1016/S0140-6736(09)60941-7Cite or Link Using DOI
Editors' note: Thromboses are a particular risk for patients immobilised after a stroke. Although many stroke guidelines suggest the use of compression stocking to reduce DVT the evidence supporting the suggestion is weak, The study investigated whether the use of compression stockings prevented DVT is such patients.
Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial
Deep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) reduce the risk of DVT. National stroke guidelines extrapolating from these trials recommend their use in patients with stroke despite insufficient evidence. We assessed the effectiveness of thigh-length GCS to reduce DVT after stroke.
In this outcome-blinded, randomised controlled trial, 2518 patients who were admitted to hospital within 1 week of an acute stroke and who were immobile were enrolled from 64 centres in the UK, Italy, and Australia. Patients were allocated via a central randomisation system to routine care plus thigh-length GCS (n=1256) or to routine care plus avoidance of GCS (n=1262). A technician who was blinded to treatment allocation undertook compression Doppler ultrasound of both legs at about 7―10 days and, when practical, again at 25―30 days after enrolment. The primary outcome was the occurrence of symptomatic or asymptomatic DVT in the popliteal or femoral veins. Analyses were by intention to treat. This study is registered, number ISRCTN28163533.
All patients were included in the analyses. The primary outcome occurred in 126 (10?0%) patients allocated to thigh-length GCS and in 133 (10?5%) allocated to avoid GCS, resulting in a non-significant absolute reduction in risk of 0?5% (95% CI −1?9% to 2?9%). Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use (64 [5%] vs 16 [1%]; odds ratio 4?18, 95% CI 2?40―7?27).
These data do not lend support to the use of thigh-length GCS in patients admitted to hospital with acute stroke. National guidelines for stroke might need to be revised on the basis of these results.
Medical Research Council (UK), Chief Scientist Office of Scottish Government, Chest Heart and Stroke Scotland, Tyco Healthcare (Covidien) USA, and UK Stroke Research Network.
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