Comparison of safety and efficacy of lower-intensity versus standard unfractionated heparin infusion nomograms for extracranial venous thromboembolism in the neurological intensive care unit

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BACKGROUND: Anticoagulation for acute venous thromboembolism (VTE) in the neurological intensive care unit is challenging because patients with acute brain injury or recent neurosurgery are at high risk for hemorrhagic complications. Unfractionated heparin infusions are commonly used, sometimes with lower activated partial thromboplastin time targets, but the safety and effectiveness of lower-intensity UFH nomograms remain poorly defined. METHODS: We performed a retrospective single-center study of patients diagnosed with acute extracranial VTE, including deep venous thrombosis and/or pulmonary embolism, between June 2018 and April 2024. Patients were grouped by treatment strategy: standard-intensity UFH targeting aPTT 60-100 s, lower-intensity UFH targeting aPTT 40-65 s, or no therapeutic anticoagulation. Treatment failure was defined as clinical or radiographic VTE progression. Hemorrhagic complications were classified as major or minor bleeding events. RESULTS: Among 443 patients with acute VTE, 236 met inclusion criteria: 81 received standard-intensity UFH, 50 lower-intensity UFH, and 105 no therapeutic anticoagulation. Major bleeding occurred more often with standard-intensity than lower-intensity UFH (18.5% vs 4.0%; p = 0.02). In multivariate analysis, standard-intensity UFH was associated with higher odds of major bleeding compared with lower-intensity UFH (adjusted OR, 4.63; 95% CI, 1.18-18.10; p = 0.03). Compared with no therapeutic anticoagulation, both lower-intensity UFH (adjusted OR, 0.32; 95% CI, 0.12-0.87; p = 0.03) and standard-intensity UFH (adjusted OR, 0.15; 95% CI, 0.05-0.43; p < 0.01) were associated with lower odds of VTE progression. CONCLUSION: Lower-intensity UFH may offer a safer therapeutic balance for selected brain-injured patients with extracranial VTE, though prospective validation is needed.

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