Venous thromboembolism after acute stroke

Background-Treatment for venous thromboembolism (VTE) is highly effective i n preventing morbidity and mortality, yet pulmonary embolism (PE) accounts for up to 25% of early deaths after stroke. This is because the current dia gnostic paradigm is reactive rather than proactive: the clinician responds to VTE when it becomes symptomatic, in the expectation that initiation of t reatment will prevent progression to more serious manifestations. This appr oach is flawed, because sudden death from PE is frequently unheralded and n onfatal symptomatic pulmonary emboli are often unrecognized or misdiagnosed . Summary of Comment-Morbidity and mortality from PE could be reduced either by more effective thromboprophylaxis or earlier diagnosis and treatment of established VTE. The fact that early use of short-term, low-dose, unfractio nated heparin (UFH) is not associated with sustained, clinically meaningful benefit suggests that a fundamental change in the diagnostic approach to V TE is needed, one which requires a greater appreciation that clinically app arent events are merely the tip of the thromboembolism iceberg. Conclusions-Research into a strategy of screening for subclinical VTE in th ese patients is needed, with a view to identifying a subgroup at risk of pr ogression to symptomatic and life-threatening events, in whom outcome might be improved by anticoagulation.