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Sidhu V, Naylor JM, Adie S, Bastiras D, Buchbinder R, Ackerman I, Harris IA. Post-discharge patient-reported non-adherence to aspirin compared to enoxaparin for venous thromboembolism prophylaxis after hip or knee arthroplasty. ANZ J Surg 2023; 93:989-994. [PMID: 36661408 DOI: 10.1111/ans.18284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/15/2022] [Accepted: 01/08/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Aspirin and enoxaparin are commonly used for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study was to compare non-adherence after discharge to aspirin or enoxaparin following THA or TKA. METHODS A subset of participants in the CRISTAL study were selected for participation. Additional inclusion criteria were no preoperative anticoagulant use and discharge from hospital before the prophylaxis period ended. The first four consecutive patients from each arm at each participating hospital were planned to be recruited (planned sample size n = 248). A patient-reported adherence questionnaire was completed by telephone at 36-41 days after THA and at 15-20 days after TKA. The primary outcome was non-adherence. Secondary outcomes were number of missed doses and the reasons for non-adherence. RESULTS There were 178 participants included from 15 sites, less than planned explained by early stopping of trial recruitment. There was no significant between-group difference in patient-reported non-adherence: 24% (17/71) for aspirin, 30% (32/107) for enoxaparin, odds ratio = 1.4 (95% CI 0.7-2.9). The mean number of missed doses was 2.5 for aspirin and 3.4 for enoxaparin (mean difference = 0.9 doses, 95% CI -1.2 to 3.1). For aspirin, the most commonly reported reason for non-adherence was forgotten doses and for enoxaparin it was clinician-recommended change. CONCLUSIONS Rates of non-adherence and the number of missing doses were similar for patients regardless of drug prescribed. The most common reasons for non-adherence were unrelated to the mode of administration.
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Affiliation(s)
- Verinder Sidhu
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Justine M Naylor
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine & Health, St George & Sutherland Clinical Campuses, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,St George and Sutherland Centre for Clinical Orthopaedic Research, Sydney, New South Wales, Australia
| | - Durga Bastiras
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Victoria, Australia
| | - Ilana Ackerman
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Victoria, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine & Health, South West Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia.,Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Institute of Musculoskeletal Health, School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
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Crush J, Seah M, Chou D, Rawal J, Hull P, Carrothers A. Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma. Arch Orthop Trauma Surg 2022; 142:3271-3277. [PMID: 34495362 DOI: 10.1007/s00402-021-04152-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. MATERIALS AND METHODS All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24 h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3 months post discharge. RESULTS The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. CONCLUSION Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.
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Affiliation(s)
- Jos Crush
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
| | - Matthew Seah
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Daud Chou
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Jaikirty Rawal
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Peter Hull
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Andrew Carrothers
- Division of Trauma and Orthopaedic Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
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van Oosterom N, Barras M, Bird R, Nusem I, Cottrell N. A Narrative Review of Aspirin Resistance in VTE Prophylaxis for Orthopaedic Surgery. Drugs 2020; 80:1889-1899. [DOI: 10.1007/s40265-020-01413-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Bala A, Murasko MJ, Burk DR, Huddleston JI, Goodman SB, Maloney WJ, Amanatullah DF. Venous thromboprophylaxis after total hip arthroplasty: aspirin, warfarin, enoxaparin, or factor Xa inhibitors? Hip Int 2020; 30:564-571. [PMID: 30990095 DOI: 10.1177/1120700019841600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Debate over the ideal agent for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) has led to changes in prescribing trends of commonly used agents. We investigate variation in utilisation and the differences in VTE incidence and bleeding risk in primary THA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors. METHODS 8829 patients were age/sex matched from a large database of primary THAs performed between 2007 and 2016. Utilisation was calculated using compound annual growth rate. Incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications, postoperative anaemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days. RESULTS Aspirin use increased by 33%, enoxaparin by 7%, and factor Xa inhibitors by 31%. Warfarin use decreased by 1%. Factor Xa inhibitors (1.7%) and aspirin (1.7%) had the lowest incidence of DVT followed by enoxaparin (2.6%), and warfarin (3.7%) at 90 days. Factor Xa inhibitors (12%) and aspirin (12%) had the lowest incidence of blood transfusion followed by warfarin (15%) and enoxaparin (17%) at 90 days. There was no difference in incidence of blood transfusion or bleeding-related complications nor any detectable difference in symptomatic PE incidence. CONCLUSIONS The utilisation of aspirin and factor Xa inhibitors increased over time. Aspirin and factor Xa inhibitors provided improved DVT prophylaxis with lower rates of postoperative anaemia compared to enoxaparin and warfarin.
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Affiliation(s)
- Abiram Bala
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - Marlon J Murasko
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - David R Burk
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
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Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients: An NATF Anticoagulation Action Initiative. Am J Med 2020; 133 Suppl 1:1-27. [PMID: 32362349 DOI: 10.1016/j.amjmed.2019.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
Hospitalized patients with acute medical illnesses are at risk for venous thromboembolism (VTE) during and after a hospital stay. Risk factors include physical immobilization and underlying pathophysiologic processes that activate the coagulation pathway and are still present after discharge. Strategies for optimal pharmacologic VTE thromboprophylaxis are evolving, and recommendations for VTE prophylaxis can be further refined to protect high-risk patients after hospital discharge. An early study of extended VTE prophylaxis with a parenteral agent in medically ill patients yielded inconclusive results with regard to efficacy and bleeding. In the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial, extended use of betrixaban halved symptomatic VTE, decreased hospital readmission, and reduced stroke and major adverse cardiovascular events compared with standard enoxaparin prophylaxis. Based on findings from APEX, the Food and Drug Administration approved betrixaban in 2017 for extended VTE prophylaxis in acute medically ill patients. In the Reducing Post-Discharge Venous Thrombo-Embolism Risk (MARINER) study, extended use of rivaroxaban halved symptomatic VTE in high-risk medical patients compared with placebo. In 2019, rivaroxaban was approved for extended thromboprophylaxis in high-risk medical patients, thus making available a new strategy for in-hospital and post-discharge VTE prevention. To address the critical unmet need for VTE prophylaxis in medically ill patients at the time of hospital discharge, the North American Thrombosis Forum (NATF) is launching the Anticoagulation Action Initiative, a comprehensive consensus document that provides practical guidance and straightforward, patient-centered recommendations for VTE prevention during hospitalization and after discharge.
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Moreno JP, Bautista M, Castro J, Bonilla G, Llinás A. Extended thromboprophylaxis for hip or knee arthroplasty. Does the administration route and dosage regimen affect adherence? A cohort study. INTERNATIONAL ORTHOPAEDICS 2019; 44:237-243. [DOI: 10.1007/s00264-019-04454-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 11/11/2019] [Indexed: 01/22/2023]
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Afzal SK, Hasan SS, Babar ZUD. A systematic review of patient-reported outcomes associated with the use of direct-acting oral anticoagulants. Br J Clin Pharmacol 2019; 85:2652-2667. [PMID: 31077431 DOI: 10.1111/bcp.13985] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/02/2019] [Accepted: 04/24/2019] [Indexed: 12/26/2022] Open
Abstract
AIMS Patient-reported outcomes (PROs) are a distinctive method of evaluating patient response to health care or treatment. This systematic review aimed to analyse the impact of PROs in patients on direct oral anticoagulant (DOAC) treatment, prescribed for any indication (e.g. venous thromboembolism treatment or atrial fibrillation) using controlled trials (CT) and real-world observational studies (OS). METHODS A systematic search of articles was conducted according to PRISMA guidelines using databases, with the last update in November 2018. The Cochrane Collaboration tool for assessing bias in randomized CTs and the Newcastle-Ottawa Scale adapted for cross-sectional studies were used. Outcomes evaluated were related to health-related quality of life (HRQoL), satisfaction, adherence and compliance. RESULTS Twenty-one original studies (6 CT, 15 OS) were included. HRQoL was assessed by 6 (1 CT, 5 OS) studies and reported that HRQoL scores were similar in patients on DOACs and warfarin. Patients prescribed DOACs presented higher HRQoL scores which were attributed to lack of intense monitoring required compared with warfarin but this was not statistically significant. The majority of studies (5 CT, 9 OS) investigated patient-reported satisfaction, indicating greater satisfaction with DOACs with significantly lower burden and increased benefit scores for patients on DOACs. Patient-reported expectations, compliance and adherence were similar for patients on DOACs and warfarin. CONCLUSION Patients appear to prefer treatment with DOACs vs warfarin. This is shown by the higher quality of life, satisfaction and adherence described in the studies. However, heterogeneity in the analysed studies does not allow firm conclusions.
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Affiliation(s)
| | - Syed Shahzad Hasan
- University of Huddersfield, Queensgate, Huddersfield, West Yorkshire, UK
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Hu Y, Li Q, Wei BG, Zhang XS, Torsha TT, Xiao J, Shi ZJ. Blood loss of total knee arthroplasty in osteoarthritis: an analysis of influential factors. J Orthop Surg Res 2018; 13:325. [PMID: 30579365 PMCID: PMC6303980 DOI: 10.1186/s13018-018-1038-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 12/11/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Total knee arthroplasty is regarded as the most effective treatment for severe knee osteoarthritis. The influential factors of blood loss in total knee arthroplasty remain controversial. The study aims to explore the influential factors of blood loss in total knee arthroplasty comprehensively. MATERIAL AND METHODS Three hundred and four osteoarthritis patients undergoing unilateral primary total knee arthroplasty were enrolled. Demographic characteristics, laboratory results, surgical protocol, and hemostatic and anticoagulation drugs were collected. Estimation of blood loss was calculated using the Gross equation. Multivariable stepwise linear regression analysis was performed to find out the influential factors. RESULTS Total blood loss reached the biggest volume (1346 ± 671 mL) in the post-operative third day. Hidden blood loss reached 465 ± 358 mL. Gender, tranexamic acid, prosthesis type, and drainage were proven to be positively correlated with the total blood loss (all P < 0.05). Male appeared to suffer more surgical blood loss than female. Posterior cruciate stabilizing prosthesis might lead to more surgical blood loss than posterior cruciate retaining prosthesis. Tranexamic acid could effectively reduce total blood loss while drainage might increase bleeding. Gender and anticoagulation drugs were correlated with hidden blood loss (both P < 0.05). Low molecular weight heparin resulted in less hidden blood loss than rivaroxaban. CONCLUSIONS Posterior cruciate retaining prosthesis and topical use of tranexamic acid were preferred to reduce total blood loss. Drainage was not recommended due to the risk of increasing bleeding. Low molecular weight heparin was recommended to prevent venous thrombosis.
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Affiliation(s)
- Yong Hu
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
| | - Qiang Li
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
- Department of Orthopaedic Surgery, Chinese Traditional Medicine Hospital of Huaihua City, Huaihua, 418000 Hunan Province China
| | - Bao-Gang Wei
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
- Department of Orthopaedic Surgery, Inner Mongolia People’s Hospital, Hohhot, 100017 Inner Mongolia China
| | - Xian-Sen Zhang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
- Department of Orthopedic Surgery, The Third People’s Hospital of Dongguan City, Dongguan, 523326 Guangdong Province China
| | | | - Jun Xiao
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
| | - Zhan-Jun Shi
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515 Guangdong Province China
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Karampinas PK, Megaloikonomos PD, Lampropoulou-Adamidou K, Papadelis EG, Mavrogenis AF, Vlamis JA, Pneumaticos SG. Similar thromboprophylaxis with rivaroxaban and low molecular weight heparin but fewer hemorrhagic complications with combined intra-articular and intravenous tranexamic acid in total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:455-460. [PMID: 30221330 DOI: 10.1007/s00590-018-2307-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To evaluate the efficacy of the combined intravenous and intra-articular administration of tranexamic acid (TXA) to control the collateral effects and complications of rivaroxaban (RIV) after total knee arthroplasty (TKA) and to compare thromboprophylaxis schemes with and without TXA, RIV and low molecular weight heparin (LMWH). MATERIALS AND METHODS We prospectively studied 158 TKA patients from 2014 to 2018. The patients were randomly assigned into three groups. Group A (46 patients) was administered intravenous and intra-articular TXA and RIV postoperatively; group B (58 patients) was administered TXA as in group A and LMWH postoperatively; and group C (54 patients) was administered saline as in group A and RIV postoperatively. We evaluated blood loss, transfusion requirements and hemorrhagic complications. RESULTS Hct and Hb values significantly decreased in group C compared to groups A and B, without any difference between groups A and B. Suction drain blood volume output was significantly higher in group C compared to group A and B, without any difference between group A and B. Hemorrhagic complications were more common in group C. No patient experienced clinical findings of VTE. CONCLUSION Combined intravenous and intra-articular administration of TXA is safe and effective in TKA, with fewer hemorrhagic complications compared to placebo. Thromboprophylaxis with RIV and LMWH is similar.
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Affiliation(s)
- Panayiotis K Karampinas
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panayiotis D Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece
| | | | - Eleftherios G Papadelis
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, 41 Ventouri Street, Holargos, 15562, Athens, Greece.
| | - John A Vlamis
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Spyros G Pneumaticos
- Third Departments of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Bala A, Huddleston JI, Goodman SB, Maloney WJ, Amanatullah DF. Venous Thromboembolism Prophylaxis After TKA: Aspirin, Warfarin, Enoxaparin, or Factor Xa Inhibitors? Clin Orthop Relat Res 2017; 475:2205-2213. [PMID: 28569372 PMCID: PMC5539035 DOI: 10.1007/s11999-017-5394-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 05/24/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is considerable debate regarding the ideal agent for venous thromboembolism (VTE) prophylaxis after TKA. Numerous studies and meta-analyses have yet to provide a clear answer and often omit one or more of the commonly used agents such as aspirin, warfarin, enoxaparin, and factor Xa inhibitors. QUESTIONS/PURPOSES Using a large database analysis, we asked: (1) What are the differences in VTE incidence in primary TKA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors? (2) What are the differences in bleeding risk among these four agents? (3) How has use of these agents changed with time? METHODS We queried a combined Humana and Medicare database between 2007 and Quarter 1 of 2016, and identified all primary TKAs performed using ICD-9 and Current Procedural Terminology codes. All patients who had any form of antiplatelet or anticoagulation prescribed within 1 year before TKA were excluded from our study cohort. We then identified patients who had either aspirin, warfarin, enoxaparin, or factor Xa inhibitors prescribed within 2 weeks of primary TKA. Each cohort was matched by age and sex. Elixhauser comorbidities and Charlson Comorbidity Index for each group were calculated. We identified 1016 patients with aspirin, and age- and sex-matched 6096 patients with enoxaparin, 6096 patients with warfarin, and 5080 patients with factor Xa inhibitors. Using ICD-9 codes, with the understanding that patients at greater risk may have had more-attentive surveillance, the incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications (bleeding requiring surgical intervention, hemorrhage, hematoma, hemarthrosis), postoperative anemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days postoperatively. A four-way chi-squared test was used to determine statistical significance. Utilization was calculated using compound annual growth rate. RESULTS There was a difference in the incidence of DVT at 90 days (p < 0.01). Factor Xa inhibitors (2.9%) had the lowest incidence of DVT followed by aspirin (3.0%) and enoxaparin (3.5%), and warfarin (4.8%). There was a difference in the incidence of PE at 90 days (p < 0.01). Factor Xa inhibitors (0.9%) had the lowest incidence of PE followed by enoxaparin (1.1%), aspirin (1.2%), and warfarin (1.6%). There was a difference in the incidence of postoperative anemia at 90 days (p < 0.01). Aspirin (19%) had the lowest incidence of postoperative anemia followed by warfarin (22%), enoxaparin (23%), and factor Xa inhibitors (23%). There was a difference in the incidence of a blood transfusion at 90 days (p < 0.01). Aspirin (7%) had the lowest incidence of a blood transfusion followed by factor Xa inhibitors (9%), warfarin (12%), and enoxaparin (13%). There were no differences in bleeding-related complications (p = 0.81) between the groups. Aspirin use increased at a compound annual growth rate of 30%, enoxaparin at 3%, and factor Xa inhibitors at 43%, while warfarin use decreased at a compound annual growth rate of -3%. CONCLUSIONS Factor Xa inhibitors had the highest growth in utilization during our study period, followed by aspirin, when compared with enoxaparin and warfarin. When selected for the right patient, factor Xa inhibitors provided improved VTE prophylaxis compared with enoxaparin and warfarin, with a lower rate of blood transfusion. Aspirin provided comparable VTE prophylaxis compared with factor Xa inhibitors with improved VTE prophylaxis compared with enoxaparin and warfarin with the lowest risk of bleeding. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Abiram Bala
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, 450 Broadway Street, Redwood City, CA, 94063-6342, USA
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, 450 Broadway Street, Redwood City, CA, 94063-6342, USA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, 450 Broadway Street, Redwood City, CA, 94063-6342, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, 450 Broadway Street, Redwood City, CA, 94063-6342, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, 450 Broadway Street, Redwood City, CA, 94063-6342, USA.
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The Incidence and Economic Burden of In-Hospital Venous Thromboembolism in the United States. J Arthroplasty 2017; 32:1063-1066. [PMID: 27866951 DOI: 10.1016/j.arth.2016.10.020] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 09/15/2016] [Accepted: 10/13/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially preventable and costly complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The in-hospital incidence and economic burden of VTE following total joint arthroplasty (TJA) in the United States is unknown. The aim of this study was to examine this issue. METHODS The Nationwide Inpatient Sample was used to estimate the total number of THA, TKA, and VTE events using International Classification of Diseases, Ninth Revision procedure codes from years 2002 to 2011. The rate of in-hospital deep vein thrombosis (DVT) and pulmonary embolism (PE), associated length of hospitalization, and current and projected in-hospital charges were obtained. RESULTS Revision arthroplasties had higher rates of in-hospital VTE compared to primary TJAs (2.5% vs 1.6%, P < .0001). Among primary TJAs, the median rate of in-hospital VTE was 0.59% (0.55%-0.63%) for primary THA and 1.01% (0.94%-1.08%) for primary TKA. Revision THAs developed more VTE events compared to revision TKAs (1.35% [1.25%-1.46%] vs 1.16% [1.07%-1.26%]). Patients with a VTE have longer hospitalizations (median primary TKA: 7 vs 3; median primary THA: 6 vs 3, P < .0001). The overall rate of VTE decreased over the last decade; however, the PE rates have remained relatively constant. Moreover, the associated costs with VTE events have increased significantly over the last decade. CONCLUSION Based on the analysis of the Nationwide Inpatient Sample database, the rate of in-hospital DVT following TJA appears to have declined over the last decade while the incidence of PE has remained constant. This may indicate that the current recommendations by the American Academy of Orthopaedic Surgeons for VTE prophylaxis are adequate for preventing DVT without increasing the rate of PE or that institutional screening and reporting of DVT has been reduced because DVTs became a "never" event.
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Hanon O, Chaussade E, Gueranger P, Gruson E, Bonan S, Gay A. Patient-Reported Treatment Satisfaction with Rivaroxaban for Stroke Prevention in Atrial Fibrillation. A French Observational Study, the SAFARI Study. PLoS One 2016; 11:e0166218. [PMID: 27935987 PMCID: PMC5147833 DOI: 10.1371/journal.pone.0166218] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/25/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND For antithrombotic treatments, Patient Reported Outcomes (PRO) and patient satisfaction with treatment are essential data for physicians because of the strong relationship between patient satisfaction and adherence to treatment. The impact of rivaroxaban on patient satisfaction and quality of life was not sufficiently documented in phase III studies. There is a need for further data in this field especially in real life conditions. METHODS The SAFARI study is composed of patients with non-valvular atrial fibrillation (AF), previously treated with vitamin K antagonist (VKA) and switched to rivaroxaban. Patient satisfaction with anticoagulant therapy was measured by the Anti-Clot Treatment Scale (ACTS), a validated 15-item patient-reported scale including a 12-item ACTS Burdens scale and a 3-item ACTS Benefits scale. Satisfaction of medication was compared between baseline and 1, 3 and 6 months. RESULTS Study population was composed of 405 patients. Mean age was 74.8 (standard deviation = 9.0) years and 63.0% were male. Mean CHA2DS2-VASc score was 3.4 (1.5) and mean HAS-BLED score was 2.9 (1.0). After 3 months of treatment with rivaroxaban, patient satisfaction improved compared with VKA: mean ACTS burdens scores significantly increased by 8.3 (8.9) points (p<0.0001) and ACTS benefits scale by 0.4 (2.9) (p<0.001). Compared with baseline, the improvement in ACTS burdens and benefits became apparent at 1 month (46.5 vs. 53.6 p<0.001 and 10.4 vs. 10.7, p<0.05 respectively) and persisted at 6 months (46.5 vs. 54.76 p<0.001 and 10.4 vs. 10.8 p = 0.02 respectively). Rivaroxaban persistence was 88.7% at 6 months. CONCLUSIONS SAFARI data support a good risk-benefit balance for rivaroxaban, with a good safety profile and encourage PRO design studies. The switch from VKA to rivaroxaban improved patient satisfaction at 1, 3 and 6 months after rivaroxaban initiation among patients with AF, particularly in reducing patient-reported anticoagulation burden.
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Affiliation(s)
- Olivier Hanon
- APHP Hôpital Broca, Service de Gériatrie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- * E-mail:
| | - Edouard Chaussade
- APHP Hôpital Broca, Service de Gériatrie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Pierre Gueranger
- CH La Chartreuse, Service de Cardiologie, Villefranche de Rouergue, France
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Gao Y, Long A, Xie Z, Meng Y, Tan J, Lv H, Zhang L, Zhang L, Tang P. The compliance of thromboprophylaxis affects the risk of venous thromboembolism in patients undergoing hip fracture surgery. SPRINGERPLUS 2016; 5:1362. [PMID: 27588255 PMCID: PMC4990524 DOI: 10.1186/s40064-016-2724-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 06/30/2016] [Indexed: 01/20/2023]
Abstract
Objective Venous thromboembolism (VTE) is major problem after hip fracture surgery with substantial morbidity and mortality. This study aimed to assess the postoperative compliance of thromboprophylaxis in elderly patients undergoing hip fracture surgery and to confirm the correlation between compliance and VTE risk. Methods This retrospective cohort study included consecutive elderly hip fracture patients who undergoing surgery. According to the thromboprophylaxis regimens, patients were divided into non-compliant group (<14days), poor compliant group (14–27days) and good compliant group (≥28days). The primary outcome was the incidence of symptomatic DVT, PE within 6weeks postoperatively. Results Between 2008 and 2012, 1214 eligible patients were included in this study. 761 (64.7%) patients were non-compliant, 224 (19.0%) patients were poor compliant, and 192 (16.3%) patients were good compliant. The overall VTE rate was 7.9% (73/1177), PE rate was 0.3% (4/1177). The VTE rate in good compliant group was lowest among three groups (4.2 vs. 5.4 vs. 9.6%, P=0.013), but the PE rates showed no significant differences (0 vs. 0.9 vs. 0.3%, P=0.241). The multivariate analysis showed that non-compliance was an independent risk factor of suffering VTE undergoing hip fracture surgery. Conclusions In this study we found fewer than 1 in 5 patients maintained compliant with thromboprophylaxis guidelines after discharge following hip surgery. This is particularly concerning because those who were non-compliant had a higher risk of VTE postoperatively compared with those who were good compliant.
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Affiliation(s)
- Yuan Gao
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Anhua Long
- Department of Orthopaedics, Beijing Luhe Hospital, Capital Medical University, Beijing, 101149 People's Republic of China.,School of Medicine, Nankai University, Tianjing, 300071 People's Republic of China
| | - Zongyan Xie
- School of Medicine, Nankai University, Tianjing, 300071 People's Republic of China
| | - Yutong Meng
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China.,School of Medicine, Nankai University, Tianjing, 300071 People's Republic of China
| | - Jing Tan
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Houchen Lv
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Lihai Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
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15
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Wilson DGG, Poole WEC, Chauhan SK, Rogers BA. Systematic review of aspirin for thromboprophylaxis in modern elective total hip and knee arthroplasty. Bone Joint J 2016; 98-B:1056-61. [DOI: 10.1302/0301-620x.98b8.36957] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 04/06/2016] [Indexed: 12/31/2022]
Abstract
Aims There is uncertainty regarding the optimal means of thromboprophylaxis following total hip and knee arthroplasty (THA, TKA). This systematic review presents the evidence for acetylsalicylic acid (aspirin) as a thromboprophylactic agent in THA and TKA and compares it with other chemoprophylactic agents. Materials and Methods A search of literature published between 2004 and 2014 was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 13 studies were eligible for inclusion. Results Evidence from one good quality randomised controlled trial (RCT) showed no difference in rates of venous thrombo-embolism (VTE) in patients given aspirin or low molecular weight heparin (LMWH) following TKA. There was insufficient evidence from trials with moderate to severe risk of bias being present to suggest aspirin is more or less effective than LMWH, warfarin or dabigatran for the prevention of VTE in TKA or THA. Compared with aspirin, rates of asymptomatic deep vein thrombosis (DVT) in TKA may be reduced with rivaroxaban but insufficient evidence exists to demonstrate an effect on incidence of symptomatic DVT. Compared with aspirin there is evidence of more wound complications following THA and TKA with dabigatran and in TKA with rivaroxaban. Some studies highlighted concerns over bleeding complications and efficacy of aspirin. Conclusion The results suggest aspirin may be considered a suitable alternative to other thromboprophylactic agents following THA and TKA. Further investigation is required to fully evaluate the safety and efficacy of aspirin. Cite this article: Bone Joint J 2016;98-B:1056–61.
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Affiliation(s)
- D. G. G. Wilson
- Brighton and Sussex University Hospitals
NHS Trust, Department of Trauma and Orthopaedics, Eastern
Road, Brighton, BN2 5BE, UK
| | - W. E. C. Poole
- Brighton and Sussex University Hospitals
NHS Trust, Eastern Road, Brighton, East Sussex, BN2
5BE, UK
| | - S. K. Chauhan
- Brighton and Sussex University Hospitals
NHS Trust, Eastern Road, Brighton, East Sussex, BN2
5BE, UK
| | - B. A. Rogers
- Brighton and Sussex University Hospitals
NHS Trust, Eastern Road, Brighton, East Sussex, BN2
5BE, UK
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16
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Wong PBY, McVicar J, Nelligan K, Bleackley JC, McCartney CJL. Factors influencing the choice of anesthetic technique for primary hip and knee arthroplasty. Pain Manag 2016; 6:297-311. [DOI: 10.2217/pmt.16.6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite evidence in the literature, continuing wide variation exists in anesthetic technique for primary joint arthroplasties. Recent evidence suggests that neuraxial anesthesia has advantages over general anesthesia in terms of mortality, major morbidity and healthcare utilization. Yet, despite the proposed benefits, utilization of these two techniques varies greatly across geographical locations, with general anesthesia being most common for total hip arthroplasty (THA) and total knee arthroplasty (TKA) in parts of the world. We uncover some factors that promote or hinder the use of neuraxial anesthesia in THA and TKA. Healthcare professionals should be familiarized with the evidence for neuraxial anesthesia, and unbiased educational material should be developed for patients regarding anesthetic options for THA and TKA in order to promote best practice.
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Affiliation(s)
- Patrick BY Wong
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Jason McVicar
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Kathleen Nelligan
- Schulich School of Medicine & Dentistry, Western University, ON, N6G 2M1, Canada
| | - Joanne C Bleackley
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Colin JL McCartney
- Department of Anesthesiology, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, General Campus, CCW 1401, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
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17
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Flierl MA, Messina MJ, Mitchell JJ, Hogan C, D'Ambrosia R. Venous thromboembolism prophylaxis after total joint arthroplasty. Orthopedics 2015; 38:252-63. [PMID: 25901614 DOI: 10.3928/01477447-20150402-06] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 12/29/2014] [Indexed: 02/03/2023]
Abstract
Venous thromboembolism (VTE) prophylaxis after total joint arthroplasty is considered best practice. However, over the past 5 years, there has been considerable debate about the ideal prophylactic regimen or modality. The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians published their most recent clinical practice guidelines about VTE prophylaxis in 2011 and 2012, respectively. In addition, the Surgical Care Improvement Project published their latest recommendations in 2014. In this review, commonly used VTE prophylaxis options and the latest clinical guidelines will be discussed.
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18
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Devitt BM. Who Will Guard the Guardians? Commentary on an article by Courtland G. Lewis, MD, et al.: "evaluation of the first-generation AAOS clinical guidelines on the prophylaxis of venous thromboembolic events in patients undergoing total joint arthroplasty. Experience with 3289 patients from a single institution". J Bone Joint Surg Am 2014; 96:e143. [PMID: 25143511 DOI: 10.2106/jbjs.n.00562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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