Intermittent pneumatic compression in patients with stroke

484 www.thelancet.com Vol 382 August 10, 2013 A patient with acute stroke has just been admitted who is immobile, and cannot walk to the bathroom without help. Looking at the patient’s unmoving legs the risk of thrombosis is clear, but a low molecular weight heparin (LMWH) might lead to bleeding, and elastic compression stockings cause skin problems. So you settle on intermittent pneumatic compression devices (IPCs)—but do they actually prevent blood clots? Decades after IPCs were fi rst reported to prevent venous thromboembolism (VTE) in surgical patients, Martin Dennis and colleagues present the results of the randomised CLOTS 3 trial in The Lancet, showing that IPCs reduce the risk of VTE in immobilised medical inpatients who have had a stroke. VTE is among the most signifi cant complications associated with hospital stay. Several entities recommend strategies to prevent hospital-acquired VTE; indeed, the US Center for Medicare Services does not compensate hospitals for treating VTEs acquired in hospital or diagnosed in the month after discharge. Yet VTE prevention measures are persistently underused, and their use is substantially lower in medical inpatients than in surgical inpatients. Is it surprising that three-quarters of hospital-acquired VTEs occur in medical patients? There are several reasons doctors fail to provide prophylaxis. One could simply forget; or hesitate to use an anticoagulant because of a fear of excessive ble eding. Medical patients often have disorders that place them at high risk of bleeding and can require invasive procedures, sometimes at short notice. Although regulatory bodies dictate use of pharmacological prophyl axis in ever-larger populations of medical inpatients, recent trials have shown a very tight balance Intermittent pneumatic compression in patients with stroke survived 2 weeks or more after subcortical lacunar ischaemic stroke. Systolic blood pressure should be lowered gradually and cautiously, in view of the potential for serious complications related to hypotension. Researchers should assess further the safety and eff ectiveness of this target in survivors of other ischaemic stroke subtypes and of haemorrhagic stroke, and continue to explore the eff ects of blood-pressure lowering in patients with acute ischaemic or haemorrhagic stroke.