1
|
Yong BSJ, Ling RR, Li R, Poh JW, Tan CS, Ho SWL, Rochwerg B, Arya R, Ramanathan K, Fan BE. Pharmacotherapy for Venous Thromboprophylaxis following Total Hip or Knee Arthroplasty: A Systematic Review and Network Meta-analysis. Semin Thromb Hemost 2024. [PMID: 38950598 DOI: 10.1055/s-0044-1787996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
The optimal pharmacological prophylaxis for venous thromboembolism (VTE) after hip or knee arthroplasty is uncertain. We conducted a systematic review and network meta-analysis to compare the efficacy and safety of various medications. We searched multiple databases for randomized clinical trials (RCTs) comparing medications (including factor Xa inhibitors, factor IIa inhibitor, warfarin, unfractionated heparin [UFH], low-molecular-weight heparin [LMWH], aspirin, pentasaccharide) for VTE prophylaxis post-arthroplasty. Outcomes included any postoperative VTE identified with screening, major bleeding, and death. We used LMWH as the main comparator for analysis and performed trial sequential analysis (TSA) for each pairwise comparison. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessments, Developments and Evaluations). We analyzed 70 RCTs (55,841 participants). Factor Xa inhibitors decreased postoperative VTE significantly compared with LMWH (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.44-0.68, high certainty). Pentasaccharides probably reduce VTE (OR: 0.61, 95% CI: 0.36-1.02, moderate certainty), while the factor IIa inhibitor dabigatran may reduce VTE (OR: 0.75, 95% CI: 0.40-1.42, low certainty). UFH probably increases VTE compared with LMWH (OR: 1.31, 95% CI: 0.91-1.89, moderate certainty), and other agents like warfarin, aspirin, placebo, and usual care without thromboprophylaxis increase VTE (high certainty). Factor Xa inhibitors may not significantly affect major bleeding compared with LMWH (OR: 1.06, 95% CI: 0.81-1.39, low certainty). No medications had a notable effect on mortality compared with LMWH (very low certainty). TSA suggests sufficient evidence for the benefit of factor Xa inhibitors over LMWH for VTE prevention. Compared with LMWH and aspirin, factor Xa inhibitors are associated with reduced VTE after hip or knee arthroplasty, without an increase in bleeding and likely no impact on mortality.
Collapse
Affiliation(s)
- Bryan Song Jun Yong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ruiqi Li
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jane Wenjin Poh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Sean Wei Loong Ho
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital Foundation NHS Trust, London, United Kingdom
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Bingwen Eugene Fan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Haematology, Tan Tock Seng Hospital, Singapore, Singapore
| |
Collapse
|
2
|
Zheng X, Nong L, Song Y, Han L, Zhang Y, Yin Q, Bian Y. Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials. Front Pharmacol 2024; 14:1326224. [PMID: 38259284 PMCID: PMC10800895 DOI: 10.3389/fphar.2023.1326224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
Background: venous thromboembolism (VTE) is one of the most common complications after major orthopaedic surgery. Recent studies have suggested that aspirin may also be effective in preventing VTE, but it is still controversial whether it can be routinely used. Objectives: To compare the efficacy and safety of aspirin against oral anticoagulants in the prevention of VTE following total hip arthroplasty (THA), total knee arthroplasty (TKA) or hip fracture surgery (HFS). Methods: Relevant publications have been obtained using electronic search databases such as PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials. gov. from inception to 20 July 2023. Only RCTs evaluating the efficacy and safety of aspirin compared with oral anticoagulants undergoing major orthopaedic surgery were included in the meta-analysis. The primary outcome reported was any VTE event (including deep vein thrombosis (DVT) and pulmonary embolism (PE)). Secondary outcomes included mortality, major bleeding (including gastrointestinal bleed, cerebrovascular hemorrhage, or any bleeding requiring a return to the theater), minor bleeding (ecchymosis, epistaxis, hematuria), and wound complications. The risk of bias for all included studies was assessed according to the Cochrane Collaboration's tool. Results: After screening 974 studies, 12 randomized clinical trials (RCTs) were included, involving 5,088 participants, including 2,540 participants in aspirin, 2,205 participants in rivaroxaban, and 323 participants in warfarin. Aspirin was found to be less effective than oral anticoagulants in thromboprophylaxis after major orthopedic surgery (RR = 1.206, 95% CI 1.053-1.383). After subgroup analysis according to the type of oral anticoagulant, the results showed that aspirin was similar to rivaroxaban and inferior to warfarin. Considering that the studies in the warfarin group were all conducted before 2000, our results need to be further confirmed. In addition, the aspirin group had a higher risk of VTE than the control group in other subgroups, including a follow-up time of ≤3 months, type of procedure as TKA, high-dose aspirin (≥650 mg qd), and no combined use of mechanical prophylaxis. In terms of safety events, aspirin did not show significant differences in major bleeding (RR = 0.952, 95% CI 0.499-1.815), all-cause mortality (RR = 1.208, 95% CI 0.459-3.177), and wound-related events (RR = 0.618, 95% CI 0.333-1.145) compared with oral anticoagulants, and aspirin was associated with a reduction in the risk of minor bleeding (RR = 0.685, 95% CI 0.552-0.850) events and total bleeding (RR = 0.726, 95% CI 0.590-0.892). Conclusion: Aspirin reduces bleeding risk after major orthopedic surgery compared with oral anticoagulants, but may sacrifice VTE prevention to some extent. Updated evidence is needed to analyze the thromboprophylaxis effects of aspirin in patients undergoing major orthopedic surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463481, identifier CRD42023463481.
Collapse
Affiliation(s)
- Xingyue Zheng
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Nong
- Department of Pharmacy, People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yujie Song
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Lizhu Han
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yuan Zhang
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Qinan Yin
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yuan Bian
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu, China
| |
Collapse
|
3
|
Zhou H, Wu M, Yu S, Xia H, Yu W, Huang K, Chen Y. Comparison of the efficacy and safety between rivaroxaban and dabigatran in the treatment of acute portal vein thrombosis in cirrhosis. BMC Gastroenterol 2023; 23:329. [PMID: 37749527 PMCID: PMC10521568 DOI: 10.1186/s12876-023-02960-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND New oral anticoagulants (NOACs) have been becoming prevalent in recent years and are increasingly used in the treatment of port vein thrombosis. The difference of the efficacy and safety between rivaroxaban and dabigatran remains unclear in the treatment of cirrhotic patients with acute portal vein thrombosis (PVT). METHODS This retrospective study included all consecutive cirrhotic patients with acute portal vein thrombosis in our institute from January 2020 to December 2021. The patients received oral anticoagulation with rivaroxaban or dabigatran. The demographic, clinical, and imaging data of patients were collected. The diagnosis of acute PVT was confirmed by imaging examinations. The severity of liver cirrhosis was assessed using Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Outcomes included recanalization (complete, partial, and persistent occlusion), liver function, bleedings, and survival. The log-rank test was used to compare Kaplan-Meier distributions of time-to-event outcomes. The Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS A total of 94 patients were included, 52 patients (55%) received rivaroxaban and 42 (45%) with dabigatran. The complete and partial recanalization of PVT was observed in 41 patients. There was no significant difference in complete recanalization, partial recanalization, and persistent occlusion between the two groups. With multivariate analysis, D-dimer (HR 1.165, 95% CI 1.036-1.311, p = 0.011) was independent predictors of complete recanalization. The Child-Pugh score (p = 0.001) was significantly improved in both two groups after anticoagulation, respectively. However, there was no difference between the two groups. The probability of survival was 94%, 95% in the rivaroxaban and dabigatran groups (log-rank p = 0.830). Major bleedings were reported in 3 patients (6%) in rivaroxaban group and 1 patient (2%) in dabigatran group (p = 0.646). Six patients (12%) in rivaroxaban group experienced minor bleeding, and five (12%) from dabigatran group (p = 0.691). CONCLUSIONS The efficacy and safety were comparable between rivaroxaban and dabigatran in the treatment of cirrhotic patients with acute portal vein thrombosis. And D-dimer can contribute to the prediction of PVT recanalization in cirrhotic patients.
Collapse
Affiliation(s)
- Haonan Zhou
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Mingdong Wu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Shixiong Yu
- Department of General Surgery, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, 400060 People’s Republic of China
| | - Han Xia
- Department of Cardiothoracic Surgery, Second Clinical Hospital, Army Medical University, Chongqing, 400000 People’s Republic of China
| | - Wu Yu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Kai Huang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Yikuan Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| |
Collapse
|
4
|
Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Parrini I, Canale ML, Giubilato S, Cornara S, Nesti M, Rao CM, Pozzi A, Binaghi G, Maloberti A, Ceravolo R, Bisceglia I, Rossini R, Temporelli PL, Amico AF, Calvanese R, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J Clin Med 2023; 12:5955. [PMID: 37762897 PMCID: PMC10531873 DOI: 10.3390/jcm12185955] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.
Collapse
Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano, 10128 Turin, Italy
| | - Maria Laura Canale
- Cardiology Department, Nuovo Ospedale Versilia Lido di Camaiore Lucca, 55049 Camaiore, Italy
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | - Irma Bisceglia
- Integrated Cardiology Services, Department of Cardio-Thoracic-Vascular, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy;
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | | | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | | |
Collapse
|
5
|
Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel) 2023; 11:49. [PMID: 37606428 PMCID: PMC10443384 DOI: 10.3390/medsci11030049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7-14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.
Collapse
Affiliation(s)
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
| |
Collapse
|
6
|
Chang H, Sadek M, Barfield ME, Rockman CB, Maldonado TS, Cayne NS, Berland TL, Garg K, Jacobowitz GR. Direct oral anticoagulant agents might be safe for patients undergoing endovenous radiofrequency and laser ablation. J Vasc Surg Venous Lymphat Disord 2023; 11:25-30. [PMID: 35872143 DOI: 10.1016/j.jvsv.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/30/2022] [Accepted: 05/03/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Studies assessing the effect of the use of anticoagulant agents on endovenous thermal ablation (ETA) have been limited to patients taking warfarin. Thus, the aim of the present study was to assess the efficacy and safety of ETA for patients taking direct oral anticoagulants (DOACs). We hypothesized that the outcome of ETA for patients taking DOACs would not be superior to the outcomes for patients taking DOACs. METHODS We performed a retrospective review to identify patients who had undergone radiofrequency ablation or endovenous laser ablation with 1470-nm diode laser fibers for symptomatic great or small saphenous venous reflux from 2018 to 2020. The patients were dichotomized into those who had received a therapeutic dose of DOACs periprocedurally and those who had not (control group). The outcomes of interest included the rates of treated vein closure at 7 days and 9 months and the incidence of deep vein thrombosis (DVT), endothermal heat-induced thrombosis (EHIT), and bleeding periprocedurally. RESULTS Of the 301 patients (382 procedures), 69 patients (87 procedures) had received DOACs and 232 control patients (295 procedures) had not received DOACs. The patients receiving DOACs were more often older (mean age, 65 years vs 55 years; P < .001) and male (70% vs 37%; P < .001), with a higher prevalence of venous thromboembolism and more severe CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (5 or 6), than were the control patients. Those receiving DOACs were more likely to have had a history of DVT (44% vs 6%; P < .001), pulmonary embolism (13% vs 0%; P < .001), and phlebitis (32% vs 15%; P < .001). Procedurally, radiofrequency ablation had been used more frequently in the control group (92% vs 84%; P = .029), with longer segments of treated veins (mean, 38 mm vs 35 mm, respectively; P = .028). No major or minor bleeding events nor any EHIT had occurred in either group. Two patients in the control group (0.7%) developed DVT; however, no DVT was observed in those in the DOAC group (P = .441). At 9 months, the treated vein had remained ablated after 94.4% of procedures for patients receiving DOACs and 98.4% of the control group (P = .163). On multivariable analysis, DOAC usage was not associated with an increased risk of vein recanalization (hazard ratio, 5.76; 95% confidence interval, 0.57-58.64; P = .139). An increased preprocedural vein diameter and the use of endovenous laser ablation were associated with an increased risk of recanalization. CONCLUSIONS In our study of patients who had undergone ETA for symptomatic saphenous venous reflux, the periprocedural use of DOACs did not adversely affect the efficacy of endovenous ablation to ≥9 months. Furthermore, DOAC use did not confer an additional risk of bleeding, DVT, or EHIT periprocedurally. DOACs may be safely continued without affecting the efficacy and durability of ETA.
Collapse
Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Michael E Barfield
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Todd L Berland
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| |
Collapse
|
7
|
A Prospective Randomized Controlled Trial Comparing Enoxaparin & Rivaroxaban for Venous Thromboembolism Prophylaxis in Orthopaedic Trauma. J Orthop Trauma 2022; 36:615-622. [PMID: 36399673 DOI: 10.1097/bot.0000000000002454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether there is a difference in orthopaedic trauma patient medication satisfaction and adherence using an oral versus subcutaneous injectable anticoagulant for venous thromboembolism chemoprophylaxis. DESIGN Randomized controlled trial. SETTING Single academic Level 1 trauma center. PARTICIPANTS One hundred twenty adult orthopaedic trauma patients with operative pelvic or lower extremity fractures were randomized and completed the study. INTERVENTION Three weeks of either the service standard 40 mg once daily enoxaparin versus trial medication 10 mg once daily rivaroxaban postoperatively. MAIN OUTCOME MEASURES Patient satisfaction as measured by the Treatment Satisfaction Questionnaire for Medication (TSQM-9). Medication adherence as measured by the Morisky Medication Adherence Scale (MMAS-8). RESULTS Medication adherence was similar in both groups. Medication satisfaction was significantly higher in the oral rivaroxaban group based on the TSQM-9 and patient-reported data. Secondary outcomes found no significant difference in the incidence of bleeding events or clinically relevant venous thromboembolism. The enoxaparin group experienced more adverse medication-related events. The rivaroxaban medication regimen costs 7.5-10× less out of pocket for uninsured patients. CONCLUSION The results of this randomized controlled trial demonstrate that patients with surgical orthopaedic trauma prefer an oral anticoagulant for postoperative venous thromboembolism chemoprophylaxis and suggest that rivaroxaban may be a viable option. Furthermore, large-scale studies are needed to confirm safety and efficacy for rivaroxaban in this population as a potential alternative to enoxaparin and aspirin. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
8
|
Ramezani A, Ghaseminejad Raeini A, Sharafi A, Sheikhvatan M, Mortazavi SMJ, Shafiei SH. Simultaneous versus staged bilateral total hip arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:392. [PMID: 35964047 PMCID: PMC9375332 DOI: 10.1186/s13018-022-03281-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Total hip arthroplasty is a common orthopedic surgery for treating primary or secondary hip osteoarthritis. Bilateral total hip replacement could be performed in a single stage or two separate stages. Each surgical procedure's reliability, safety, and complications have been reported controversially. This study aimed to review the current evidence regarding the outcomes of simultaneous and staged bilateral total hip arthroplasty. METHODS We conducted a meta-analysis using MEDLINE, EMBASE, Web of Science, and Scopus databases. Eligible studies compared complications and related outcomes between simultaneous and staged bilateral THA. Two reviewers independently screened initial search results, assessed methodological quality, and extracted data. We used the Mantel-Haenszel method to perform the meta-analysis. RESULTS In our study, we included 29,551 patients undergoing simBTHA and 74,600 patients undergoing stgBTHA. In favor of the simBTHA, a significant reduction in deep vein thrombosis (DVT) and systemic, local, and pulmonary complications was documented. However, we evidenced an increased pulmonary embolism (PE) and periprosthetic fracture risk in simBTHA. In the simBTHA, total blood loss, length of hospital stay, and total cost were lower. CONCLUSION This meta-analysis shows that simultaneous bilateral THA accompanies fewer complications and lower total cost. Well-designed randomized controlled trials are needed to provide robust evidence.
Collapse
Affiliation(s)
- Akam Ramezani
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Ghaseminejad Raeini
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Sharafi
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Sheikhvatan
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Heidelberg Medical Hospital, Heidelberg, Germany
| | | | - Seyyed Hossein Shafiei
- Orthopedic Department, Orthopedic Surgery Research Center (OSRC), Sina University Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
9
|
Incremental net monetary benefit of direct oral anticoagulants for the prevention of venous thromboembolism after total knee or hip replacement: A systematic review and meta-analysis. Thromb Res 2022; 216:74-83. [PMID: 35753113 DOI: 10.1016/j.thromres.2022.06.004] [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: 03/04/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION This meta-analysis was conducted to quantitatively pool the incremental net benefit (INB) of using direct oral anticoagulants (DOACs) for the prevention of venous thromboembolism (VTE) in patients undergoing total knee or hip replacements (TKR or THR). MATERIALS AND METHODS We performed a comprehensive search in several databases published before June 2021. Studies were included if they were cost-effectiveness analyses reporting cost per quality-adjusted life-year or life-year of DOACs compared to low molecular-weight heparins (LMWHs) or other anticoagulant agents for the prevention of VTE after TKR or THR. Risk of bias was also assessed using the biases in economic studies (ECOBIAS) checklist. Various monetary units were converted to purchasing power parity, adjusted to 2020 US dollars. The INBs were pooled across studies using a random-effects model, stratified by high-income countries (HICs) and low- and middle-income countries (LMICs). Heterogeneity was assessed using the I2 statistic. RESULTS A total of 49 comparisons (TKR = 25 and THR = 24) from 16 studies was included. In HICs, DOACs were cost-effective compared to LMWHs from the health care system/payer perspective for the prevention of VTE after both TKR and THR with corresponding INBs (95 % CI; I2) of $231.91 ($178.71, $285.11; 0 %) and $254.99 ($159.20, $350.77; 27.79 %), respectively. In LMICs, DOACs were not cost-effective compared to LMWHs for both TKR and THR with the INBs of $94.13 (-$40.21, $228.47; 97.04 %) and $80.55 (-$157.37, $318.47; 99.78 %), respectively. No evidence of small-study effects was identified in any analyses. The cost-effectiveness of using DOACs for TKR and THR in HICs was robust across a series of sensitivity analyses. CONCLUSIONS DOACs were cost-effective as compared to LMWHs for VTE prophylaxis following TKR and THR surgeries in HICs. Further studies from LMICs are warranted.
Collapse
|
10
|
Clinical use of low-dose parenteral anticoagulation, incidence of major bleeding and mortality: a multi-centre cohort study using the French national health data system. Eur J Clin Pharmacol 2022; 78:1137-1144. [PMID: 35385975 DOI: 10.1007/s00228-022-03318-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/29/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE Low-dose parenteral anticoagulation has demonstrated its efficacy for venous thromboembolism prophylaxis in randomized trials. However, current practice is not widely documented. In ambulatory settings, we aimed to provide an overview of the clinical use of low-dose parenteral anticoagulation in France and to assess the incidence of major bleeding and death rates. METHODS A population-based prospective cohort study using the French national health data system (SNIIRAM) identified 142,815 adults living in five well-defined geographical areas who had a course of low-dose parenteral anticoagulants (a total of 150,389 courses) in the period 2013-2015. The main outcome measures were the types of low-dose parenteral anticoagulant, the duration and the clinical context. Adjusted incidence rate ratios (IRR) were derived from Poisson models. RESULTS Enoxaparin was the most frequently prescribed anticoagulant (58.9%) followed by tinzaparin (27.3%) and fondaparinux (10.9%). Patients receiving unfractionated heparin (N = 766, 0.53%) were older, more frequently had renal disease (48.75%) and had a higher modified HAS-B(L)ED score (≥ 3 in 61.6%) than patients receiving low-molecular weight heparin (LMWH). Surgical thrombo-prophylaxis was the most frequent indication (47.6%), followed by medical prophylaxis (29.9%). Course durations were in line with regulatory agency specifications. Only 43 (0.028%) major bleeding events and 478 (0.32%) deaths were observed. Adjusted IRRs for major bleeding or death were not significantly different for dalteparin/nadroparin, tinzaparin or fondaparinux compared to enoxaparin. CONCLUSION Very low incidence rates of major bleeding and all-cause mortality were observed. Our study confirms the safety of LMWHs and fondaparinux in thrombo-prophylaxis in ambulatory settings. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02886533.
Collapse
|
11
|
|
12
|
Marcucci M, Etxeandia-Ikobaltzeta I, Yang S, Germini F, Gupta S, Agarwal A, Ventresca M, Tang S, Morgano GP, Wang M, Ahmed MM, Neumann I, Izcovich A, Criniti J, Popoff F, Devereaux PJ, Dahm P, Anderson D, Lavikainen LI, Tikkinen KAO, Guyatt GH, Schünemann HJ, Violette PD. Benefits and harms of direct oral anticoagulation and low molecular weight heparin for thromboprophylaxis in patients undergoing non-cardiac surgery: systematic review and network meta-analysis of randomised trials. BMJ 2022; 376:e066785. [PMID: 35264372 PMCID: PMC8905353 DOI: 10.1136/bmj-2021-066785] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To systematically compare the effect of direct oral anticoagulants and low molecular weight heparin for thromboprophylaxis on the benefits and harms to patients undergoing non-cardiac surgery. DESIGN Systematic review and network meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL), up to August 2021. REVIEW METHODS Randomised controlled trials in adults undergoing non-cardiac surgery were selected, comparing low molecular weight heparin (prophylactic (low) or higher dose) with direct oral anticoagulants or with no active treatment. Main outcomes were symptomatic venous thromboembolism, symptomatic pulmonary embolism, and major bleeding. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for network meta-analyses. Abstracts and full texts were screened independently in duplicate. Data were abstracted on study participants, interventions, and outcomes, and risk of bias was assessed independently in duplicate. Frequentist network meta-analysis with multivariate random effects models provided odds ratios with 95% confidence intervals, and GRADE (grading of recommendations, assessment, development, and evaluation) assessments indicated the certainty of the evidence. RESULTS 68 randomised controlled trials were included (51 orthopaedic, 10 general, four gynaecological, two thoracic, and one urological surgery), involving 45 445 patients. Low dose (odds ratio 0.33, 95% confidence interval 0.16 to 0.67) and high dose (0.19, 0.07 to 0.54) low molecular weight heparin, and direct oral anticoagulants (0.17, 0.07 to 0.41) reduced symptomatic venous thromboembolism compared with no active treatment, with absolute risk differences of 1-100 per 1000 patients, depending on baseline risks (certainty of evidence, moderate to high). None of the active agents reduced symptomatic pulmonary embolism (certainty of evidence, low to moderate). Direct oral anticoagulants and low molecular weight heparin were associated with a 2-3-fold increase in the odds of major bleeding compared with no active treatment (certainty of evidence, moderate to high), with absolute risk differences as high as 50 per 1000 in patients at high risk. Compared with low dose low molecular weight heparin, high dose low molecular weight heparin did not reduce symptomatic venous thromboembolism (0.57, 0.26 to 1.27) but increased major bleeding (1.87, 1.06 to 3.31); direct oral anticoagulants reduced symptomatic venous thromboembolism (0.53, 0.32 to 0.89) and did not increase major bleeding (1.23, 0.89 to 1.69). CONCLUSIONS Direct oral anticoagulants and low molecular weight heparin reduced venous thromboembolism compared with no active treatment but probably increased major bleeding to a similar extent. Direct oral anticoagulants probably prevent symptomatic venous thromboembolism to a greater extent than prophylactic low molecular weight heparin. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018106181.
Collapse
Affiliation(s)
- Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Stephen Yang
- Department of Anaesthesia, Jewish General Hospital, Montreal, QC, Canada
| | - Federico Germini
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shyla Gupta
- Department of Medicine, Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Arnav Agarwal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Ventresca
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shaowen Tang
- Department of Epidemiology, Nanjing Medical University, Nanjing, China
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Mengxiao Wang
- Department of Science, McMaster University, Hamilton, ON, Canada
- Department of Mathematics, University of Waterloo, Waterloo, ON, Canada
| | | | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Ariel Izcovich
- Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - Juan Criniti
- Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - Federico Popoff
- Department of Internal Medicine, Hospital Alemán, Buenos Aires, Argentina
| | - P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Philipp Dahm
- Minneapolis Veterans Affair Health Care System, Urology Section, Minneapolis, MN, USA
- University of Minnesota, Department of Urology, Minneapolis, MN, USA
| | - David Anderson
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Kari A O Tikkinen
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelian Central Hospital, Lappeenranta, Finland
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael DeGroote Cochrane Canada Centre-Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Philippe D Violette
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
13
|
Yi YH, Gong S, Gong TL, Zhou LY, Hu C, Xu WH. New Oral Anticoagulants for Venous Thromboembolism Prophylaxis in Total Hip and Knee Arthroplasty: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2022; 12:775126. [PMID: 35111051 PMCID: PMC8801787 DOI: 10.3389/fphar.2021.775126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background: There is controversy over whether use of new oral anticoagulants (NOACs) associates with increased hemorrhage risk compared with non-NOAC. Meanwhile, determining which NOAC to use remains unclear. We aimed to summarize the evidence about NOACs in venous thromboembolism (VTE) prevention for patients with total hip and knee arthroplasty (THA and TKA). Methods: We searched RCTs assessing NOACs for VTE prophylaxis in adults undergoing THA and TKA in Medline, Embase, and Cochrane up to May 2021. Primary outcomes were VTE [included deep vein thrombosis (DVT) and pulmonary embolism (PE)], major VTE, and major bleeding. The rank probabilities of each treatment were summarized by the surface under the cumulative ranking curve area (SUCRA). Results: 25 RCTs with 42,994 patients were included. Compared with non-NOAC, NOACs were associated with a decreased risk of VTE (RR 0.68; 95% CI 0.55–0.84) and major VTE (RR = 0.52; 95% CI 0.35–0.76). Additionally, rivaroxaban, apixaban, and edoxaban but not dabigatran and betrixaban, did confer a higher efficacy compared with non-NOAC. None of the individual NOACs increased the risk of bleeding, while apixaban and betrixaban were even associated with a decreased risk of bleeding. In the comparison of different NOACs, rivaroxaban was associated with the greatest benefits in VTE (SUCRA = 79.6), DVT (SUCRA = 88.8), and major VTE (SUCRA = 89.9) prevention. Furthermore, subgroup analysis confirmed that NOACs associated with a higher efficacy tendency in patients with follow-up duration <60 days than follow-up duration ≥60 days. Conclusion: Evidence suggests that NOACs exert more benefits on VTE prophylaxis, and none of the individual NOACs increased hemorrhage compared with non-NOAC. Among various NOACs, rivaroxaban is recommended in patients with lower bleeding risk, and apixaban is recommended in patients with higher bleeding risk. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021266890].
Collapse
Affiliation(s)
- Yi-Hu Yi
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tian-Lun Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling-Yun Zhou
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Can Hu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei-Hua Xu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
14
|
Pham A, Heib A, Goodman E, Cotto R, Jafari P, Lipsitz E, Indes J. Warfarin Versus Direct Oral Anticoagulants For Patients Needing Treatment For Distal Deep Vein Thrombosis. J Vasc Surg Venous Lymphat Disord 2022; 10:826-831.e1. [DOI: 10.1016/j.jvsv.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
|
15
|
Bass AR, Zhang Y, Mehta B, Do HT, Russell LA, Sculco PK, Goodman SM. Periprosthetic Joint Infection Is Associated with an Increased Risk of Venous Thromboembolism Following Revision Total Knee Replacement: An Analysis of Administrative Discharge Data. J Bone Joint Surg Am 2021; 103:1312-1318. [PMID: 33750744 DOI: 10.2106/jbjs.20.01486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the relationship between infection and the risk of risk of venous thromboembolism (VTE) following orthopaedic surgery. We assessed the 90-day risk of VTE following revision total knee replacement to measure the association between periprosthetic joint infection and the risk of postoperative VTE. METHODS We used New York Statewide Planning and Research Cooperative System data to identify all New York State residents undergoing revision total knee replacement from 1998 to 2014. ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes were used to identify comorbidities and to classify the indication for revision total knee replacement as aseptic, infection, or fracture. The primary outcome was any diagnosis code for VTE recorded for the revision surgery and/or subsequent admissions within 90 days. A multivariable logistic regression model that included demographic characteristics and comorbidities was used to estimate the risk of VTE after revision for infection or fracture, with aseptic revision as the reference group. RESULTS The present study included 25,441 patients who were managed with revision total knee replacement; the indication for revision was aseptic for 17,563 patients (69%), infection for 7,075 (28%), and fracture for 803 (3%). The mean age (and standard deviation) was 66 ± 12 years, 15,592 (61%) of the patients were female, 3,198 (13%) were Black, 1,192 (5%) were smokers, and 4,222 (17%) were obese. Seven hundred and nineteen patients (2.8%) had VTE within the 90 days after revision total knee replacement, including 387 (1.5%) during the admission for the revision procedure. The 90-day incidence of VTE was 2.1% after aseptic revision, 4.3% after revision for infection, and 5.9% after revision for fracture. The adjusted odds ratio (aOR) for VTE relative to aseptic revision was 2.01 (95% confidence interval [CI], 1.72 to 2.35) for septic revision total knee replacement and 2.62 (95% CI, 1.91 to 3.6) for fracture. A history of VTE was also a strong risk factor for VTE following revision total knee replacement (aOR, 2.01; 95% CI, 1.48 to 2.71). CONCLUSIONS We found that the odds of VTE after revision total knee replacement for infection were double those after aseptic revision total knee replacement. Although fracture accounts for a small percentage of revision total knee replacements, the risk of VTE was 2.6-fold higher after these procedures. The indication for revision total knee replacement should be considered when choosing postoperative VTE prophylaxis. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
| | - Yi Zhang
- Hospital for Special Surgery, New York, NY
| | | | - Huong T Do
- Hospital for Special Surgery, New York, NY
| | | | | | | |
Collapse
|
16
|
Muscatelli SR, Charters MA, Hallstrom BR. Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture. Arthroplast Today 2021; 10:105-107. [PMID: 34337116 PMCID: PMC8318891 DOI: 10.1016/j.artd.2021.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/02/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022] Open
Abstract
Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines.
Collapse
Affiliation(s)
- Stefano R. Muscatelli
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Brian R. Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI, USA
- Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Coordinating Center, University of Michigan Health System, Ann Arbor, MI, USA
- Corresponding author. 1500 E. Medical Center Dr., TC 2912, Ann Arbor, MI 48109-5328, USA. Tel.: +1 734 646 9191.
| |
Collapse
|
17
|
Muscatelli SR, Zheng H, Hughes RE, Cowen ME, Hallstrom BR. Non-Inferiority of Aspirin for Venous Thromboembolism Prophylaxis After Hip Arthroplasty in a Statewide Registry. J Arthroplasty 2021; 36:2068-2075.e2. [PMID: 33589277 DOI: 10.1016/j.arth.2021.01.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/05/2021] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Uncertainty remains surrounding the use of aspirin as a sole chemoprophylactic agent to reduce the risk of venous thromboembolism (deep vein thrombosis or pulmonary embolism) and bleeding after primary total hip arthroplasty. METHODS We performed a non-inferiority analysis of a retrospective cohort of patients undergoing total hip arthroplasty from April 1, 2013 to December 31, 2018. Cases were retrieved from the Michigan Arthroplasty Registry Collaborative Quality Initiative database and performed by 355 surgeons at 61 hospitals throughout Michigan. Surgical setting ranged from small community hospitals to large academic and non-academic centers. The primary outcomes were post-operative venous thromboembolism event or death and bleeding event. RESULTS Of the 59,747 patients included, 32,878 (55.03%) were female, and the mean age was 64.5. A total of 462 (0.77%) composite venous thromboembolism events occurred. There were 221 (0.71%) and 129 (0.80%) venous thromboembolism events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for composite venous thromboembolism events (odds ratio 0.99, 95% confidence interval 0.79-1.26, P < .001). Bleeding events occurred in 767 (1.28%) patients, with 304 (0.97%) and 281 (1.74%) bleeding events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for bleeding events (odds ratio 0.62, 95% confidence interval 0.52-0.74, P < .001). CONCLUSION Aspirin is not inferior to other anticoagulants as pharmacologic venous thromboembolism prophylaxis with regards to post-operative risk of venous thromboembolism or bleeding. Sole use of aspirin for venous thromboembolism prophylaxis after total hip arthroplasty should be considered in the appropriate patient.
Collapse
Affiliation(s)
- Stefano R Muscatelli
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Huiyong Zheng
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Richard E Hughes
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Mark E Cowen
- Quality Insitute, St. Joseph Mercy Hospital, Ann Arbor, MI
| | - Brian R Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| |
Collapse
|
18
|
Mottla JL, Murphy JP, Keeling LE, Verstraete R, Zawadsky MW. Role of arthroplasty in the Jehovah's Witness population. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1097-1104. [PMID: 33389053 DOI: 10.1007/s00590-020-02852-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/14/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Total joint arthroplasties aim to improve quality of life from joint-related pain. Jehovah's Witnesses refuse blood products due to their religious beliefs. Surgeons may be reluctant to perform arthroplasty procedures on these patients for fear of uncontrolled bleeding. However, we hypothesize that through preoperative optimization, arthroplasty can be performed safely. METHODS We retrospectively reviewed 184 total joint arthroplasties in Jehovah's Witnesses between 2011 and 2019. Each patient was enrolled in the institutions' Bloodless Medicine program. Hemoglobin levels were recorded through standard laboratory testing while in the hospital. Primary outcomes were changes in preoperative and postoperative hemoglobin measures, short-term outcomes measures, and complications. RESULTS A total of 103 total knee arthroplasties (8 revisions) and 81 total hip arthroplasties (5 revisions) were performed. Hemoglobin drift was 2.5 ± 1.0 for primary TKA and 2.6 ± 1.3 for primary THA (p = 0.570). Hemoglobin drift was 1.9 ± 0.9 for revision TKA and 1.9 ± 0.2 for revision THA (p = 0.990). Only 2.7% of patients met the transfusion requirement of 7 g/dL. The major complication rate for the cohort was 1.6% systemic and 4.9% local, respectively, with no mortalities. The overall readmission rate was 2.7%. CONCLUSION To our knowledge, this is the largest reported sample of Jehovah's Witness patients undergoing total joint arthroplasty. Postoperative hemoglobin values did not prompt additional intervention in the overwhelming majority of patients, and complication rates were acceptable. Our data suggest that primary arthroplasty is safe in the Jehovah's Witness population. Additionally, we show preliminary evidence that revision arthroplasty is safe in Jehovah's Witness patients.
Collapse
Affiliation(s)
- Jay L Mottla
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA.
| | - Jordan P Murphy
- Georgetown University School of Medicine, Washington, DC, USA
| | - Laura E Keeling
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA
| | - Richard Verstraete
- Department of Bloodless Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mark W Zawadsky
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA
| |
Collapse
|
19
|
Ketfi C, Boutigny A, Mohamedi N, Bouajil S, Magnan B, Amah G, Dillinger JG. Risk of venous thromboembolism in rheumatoid arthritis. Joint Bone Spine 2020; 88:105122. [PMID: 33346109 DOI: 10.1016/j.jbspin.2020.105122] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/24/2020] [Indexed: 01/08/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune joint disease with persistent systemic inflammation. Patients with RA suffer from joint pain and physical disability, but have their prognosis mostly driven by cardiovascular events, including venous thromboembolism (VTE). The risk of VTE is more than double in patients with RA compared with the general population. The incidence rate in patients with RA is estimated around 4 cases per 1000 person-years. The etiology of thrombotic tendency in RA is linked to various mechanisms and causal factors (antiphsolpholid antibodies, hyperhomocyteinemia, inflammation…): vascular injury, hypercoagulation, and venous stasis, the three components of the Virchow's triad, are activated in patients with RA. In clinical practice, situations that put patients for VTE should be identified (e.g., surgery, first year after RA diagnosis, hospitalization for acute illness…). Patients with RA are exposed to reversible risk factors, such as major surgery (knee or hip surgery) or hospitalization with immobilization. Similarly, uncontrolled RA, which is defined by the necessity to switch a biological disease-modifying anti-rheumatic drugs (DMARD), increases the incidence of VTE in observational studies. Moreover, DMARDs may impact the risk of VTE, especially in the time window after first prescription. Several biological DMARDs like tofacitinib have been associated with an increased risk of VTE. Therefore, patients with RA may require specific measures in terms of VTE diagnosis and management. In this review, we provide current insights into the pathophysiology, epidemiology, clinical considerations, and treatment strategies of VTE highlighting gaps in evidence and perspectives in patients with RA.
Collapse
Affiliation(s)
- Chahinez Ketfi
- Université de Paris, AP-HP, Hôpital Lariboisière, Physiologie Clinique-Explorations Fonctionnelles, 2, rue A Paré, 75010 Paris, France
| | - Alexandre Boutigny
- Université de Paris, AP-HP, Hôpital Lariboisière, Physiologie Clinique-Explorations Fonctionnelles, 2, rue A Paré, 75010 Paris, France; INSERM U1148, 46, rue Henri-Huchard, 75018 Paris, France
| | - Nassim Mohamedi
- Université de Paris, AP-HP, Hôpital Lariboisière, Physiologie Clinique-Explorations Fonctionnelles, 2, rue A Paré, 75010 Paris, France
| | - Sara Bouajil
- Université de Paris, AP-HP, Hôpital Lariboisière, Physiologie Clinique-Explorations Fonctionnelles, 2, rue A Paré, 75010 Paris, France; Department of Cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, 2, Rue Ambroise-Paré, 75010 Paris, France
| | - Benjamin Magnan
- Université de Paris, AP-HP, Hôpital Lariboisière, Physiologie Clinique-Explorations Fonctionnelles, 2, rue A Paré, 75010 Paris, France
| | - Guy Amah
- Université de Paris, AP-HP, Hôpital Lariboisière, Physiologie Clinique-Explorations Fonctionnelles, 2, rue A Paré, 75010 Paris, France
| | - Jean-Guillaume Dillinger
- Université de Paris, AP-HP, Hôpital Lariboisière, Physiologie Clinique-Explorations Fonctionnelles, 2, rue A Paré, 75010 Paris, France; Department of Cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, 2, Rue Ambroise-Paré, 75010 Paris, France.
| |
Collapse
|
20
|
Jenny JY, Bulaid Y, Boisrenoult P, Bonin N, Henky P, Tracol P, Chouteau J, Courtin C, Henry MP, Schwartz C, Mertl P, De Ladoucette A. Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program. Orthop Traumatol Surg Res 2020; 106:1533-1538. [PMID: 33127330 DOI: 10.1016/j.otsr.2020.02.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol. HYPOTHESIS The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol. METHODS This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months. RESULTS Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA. DISCUSSION The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed. LEVEL OF EVIDENCE IV; Prospective cohort study without control group.
Collapse
Affiliation(s)
- Jean-Yves Jenny
- Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67200 Strasbourg, France.
| | - Yassine Bulaid
- Centre Hospitalier Universitaire Amiens-Picardie, 80054 Amiens cedex 1, France
| | - Philippe Boisrenoult
- Center Hospitalier de Versailles, 177, rue de Versailles, 78150 Le Chesnay, France
| | - Nicolas Bonin
- Lyon Ortho Clinic, 29B, avenue des Sources, 69009 Lyon, France
| | - Pierre Henky
- Clinique Rhéna, 10, rue François Epailly, 67000 Strasbourg, France
| | - Philippe Tracol
- Cité Santé Plus, 1021, avenue Pierre Mendès France, 84300 Cavaillon, France
| | - Julien Chouteau
- Clinique d'Argonay, 685, route des Menthonnex, 74370 Argonay, France
| | - Cyril Courtin
- Hospices Civils de Lyon-Hôpital Lyon Sud, 165, chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Marc-Pierre Henry
- Centre Hospitalier Régional Universitaire de Brest, 2, avenue Foch, 29609 Brest cedex, France
| | - Claude Schwartz
- Polyclinique des Trois Frontières, 8, rue Saint-Damien, 68300 Saint-Louis, France
| | - Patrice Mertl
- Centre Hospitalier Universitaire Amiens-Picardie, 80054 Amiens cedex 1, France
| | | |
Collapse
|
21
|
How I treat obese patients with oral anticoagulants. Blood 2020; 135:904-911. [PMID: 31978224 DOI: 10.1182/blood.2019003528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/13/2020] [Indexed: 11/20/2022] Open
Abstract
Obesity has become a major threat to health worldwide. The prevalence of obesity is rapidly increasing, so much so that the World Health Organization has declared obesity as a global epidemic. Obesity is associated with multiple health problems, including venous thromboembolism and atrial fibrillation, both of which are treated with anticoagulation. However, obesity and treatments for obesity such as bariatric surgery can influence absorption, excretion, pharmacokinetics, and pharmacodynamics of various anticoagulants. This results in uncertainty regarding the best antithrombotic strategies in this population, particularly in the morbidly obese. In the recent years, several studies have attempted to investigate anticoagulation use in this population and provided more insight. Herein, we present 4 cases of anticoagulant use in the obese to illustrate the common challenges faced by clinicians and discuss our approach. Whenever possible, we provide a review of the literature and base our recommendations on the best available evidence.
Collapse
|
22
|
Abstract
Abstract
Direct oral anticoagulants (
DOAC
s) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist.
DOAC
s are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010,
DOAC
s have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of
DOAC
s, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of
DOAC
s and act as a practical reference for clinicians to optimize
DOAC
use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
Collapse
Affiliation(s)
| | - Eric Stecker
- Electrophysiology Section Knight Cardiovascular Institute Oregon Health & Science University Portland OR
| | - Bruce A. Warden
- Center for Preventive Cardiology Knight Cardiovascular Institute Oregon Health & Science University Portland OR
| |
Collapse
|
23
|
Abstract
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long-standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
Collapse
Affiliation(s)
| | - Eric Stecker
- Electrophysiology SectionKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Bruce A. Warden
- Center for Preventive CardiologyKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| |
Collapse
|
24
|
Ko D, Kapoor A, Rose AJ, Hanchate AD, Miller D, Winter MR, Palmisano JN, Henault LE, Fredman L, Walkey AJ, Tripodis Y, Karcz A, Hylek EM. Temporal trends in pharmacologic prophylaxis for venous thromboembolism after hip and knee replacement in older adults. Vasc Med 2020; 25:450-459. [PMID: 32516054 DOI: 10.1177/1358863x20927096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trends in prescription for venous thromboembolism (VTE) prophylaxis following total hip (THR) and knee replacement (TKR) since the approval of direct oral anticoagulants (DOACs) and the 2012 guideline endorsement of aspirin are unknown, as are the risks of adverse events. We examined practice patterns in the prescription of prophylaxis agents and the risk of adverse events during the in-hospital period (the 'in-hospital sample') and 90 days following discharge (the 'discharge sample') among adults aged ⩾ 65 undergoing THR and TKR in community hospitals in the Institute for Health Metrics database over a 30-month period during 2011 to 2013. Eligible medications included fondaparinux, DOACs, low molecular weight heparin (LMWH), other heparin products, warfarin, and aspirin. Outcomes were validated by physician review of source documents: VTE, major hemorrhage, cardiovascular events, and death. The in-hospital and the discharge samples included 10,503 and 5722 adults from 65 hospitals nationwide, respectively (mean age 73, 74 years; 61%, 63% women). Pharmacologic prophylaxis was near universal during the in-hospital period (93%) and at discharge (99%). DOAC use increased substantially and was the prophylaxis of choice for nearly a quarter (in-hospital) and a third (discharge) of the patients. Aspirin was the sole discharge prophylactic agent for 17% and 19% of patients undergoing THR and TKR, respectively. Warfarin remained the prophylaxis agent of choice for patients aged 80 years and older. The overall risk of adverse events was low, at less than 1% for both the in-hospital and discharge outcomes. The low number of adverse events precluded statistical comparison of prophylaxis regimens.
Collapse
Affiliation(s)
- Darae Ko
- Section of Cardiovascular Medicine, Boston University Medical Center, Boston, MA, USA
| | - Alok Kapoor
- Division of Hospital Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Adam J Rose
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Amresh D Hanchate
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Donald Miller
- Center for Healthcare Organization and Implementation Research, Bedford VA, MA, USA
| | - Michael R Winter
- Data Coordinating Center, Boston University School of Public Health, Boston, MA, USA
| | - Joseph N Palmisano
- Data Coordinating Center, Boston University School of Public Health, Boston, MA, USA
| | - Lori E Henault
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Lisa Fredman
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Allan J Walkey
- Section of Pulmonary, Allergy, Sleep, and Critical Care, Boston University Medical Center, Boston, MA, USA
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Anita Karcz
- Institute for Health Metrics, Cambridge, MA, USA
| | - Elaine M Hylek
- Section of General Internal Medicine, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
25
|
Cheng Y, Liu J, Su Y, Zhao H, Zhao Y, Wen M, Lu S, Zhang W, Wu J. Clinical Impact of Coagulation and Fibrinolysis Markers for Predicting Postoperative Venous Thromboembolism in Total Joint Arthroplasty Patients. Clin Appl Thromb Hemost 2020; 25:1076029619877458. [PMID: 31608652 PMCID: PMC6900621 DOI: 10.1177/1076029619877458] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
One common complication after joint arthroplasty is venous thromboembolism (VTE).
Therefore, it is essential to measure the changes in coagulation and fibrinolysis in order
to predict VTE among patients who underwent joint arthroplasty. This study aimed to
identify potential useful biomarkers for prognosing to VTE. This was a prospective cohort
study enrolling 83 patients who underwent joint arthroplasty. The levels of
d-dimer, thrombin–antithrombin complex (TAT), plasmin–α2-antiplasmin complex
(PIC), soluble thrombomodulin, and tissue plasminogen activator inhibitor complex were
measured on day 0 (before surgery) and days 1, 3, and 6 after surgery. Ultrasound
examination was used to diagnose VTE on preoperative day 0 and postoperative day 6. A
total of 35 patients developed VTE after surgery. Patients with VTE exhibited
significantly higher levels of d-dimer and TAT on postoperative days 3 and 6 (all
P < .05). The area under curves (AUC) of receiver operating
characteristic (ROC) were 0.65 and 0.68 and 0.68 and 0.74 for d-dimer and TAT
levels on postoperative days 3 and 6, respectively. The level of TAT/PIC ratio on
postoperative day 6 was significantly increased among patients with VTE compared to
non-VTE patients (P < .0001). In addition, the AUC of ROC, cutoff
level, sensitivity, specificity, positive-predictive value, and negative-predictive value
of TAT/PIC ratio were 0.78, 4.03 ng/TU, 97.14%, 33.33%, 51.52%, and 94.12%, respectively.
The high sensitivity and negative predictive value of TAT/PIC ratio make it a potential
prognostic index for diagnosing VTE during the early phase of postoperative joint
arthroplasty.
Collapse
Affiliation(s)
- Yuying Cheng
- Department of laboratory medicine, Peking University Fourth School of
Clinical Medicine, Beijing, China
| | - Jian Liu
- Adult reconstruction department, Beijing Jishuitan Hospital, Beijing,
China
| | - Yu Su
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Huiru Zhao
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Yujing Zhao
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Meng Wen
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Shan Lu
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Wenjie Zhang
- Department of laboratory medicine, Peking University Fourth School of
Clinical Medicine, Beijing, China
| | - Jun Wu
- Department of laboratory medicine, Peking University Fourth School of
Clinical Medicine, Beijing, China
- Jun Wu, Peking University Fourth School of Clinical
Medicine, Beijing 100035, China.
| |
Collapse
|
26
|
Controversial Topics in Total Knee Arthroplasty: A Five-Year Update (Part 2). JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00048. [PMID: 32159069 PMCID: PMC7028789 DOI: 10.5435/jaaosglobal-d-19-00048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This review article examines updates to the literature during the past 5 years on numerous topics which were felt to have ongoing controversy. These topics include venous thromboprophylaxis, tranexamic acid usage, tourniquet usage, and wound closure techniques.
Collapse
|
27
|
Parakh RS, Sabath DE. Venous Thromboembolism: Role of the Clinical Laboratory in Diagnosis and Management. J Appl Lab Med 2019; 3:870-882. [DOI: 10.1373/jalm.2017.025734] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/02/2018] [Indexed: 12/31/2022]
Abstract
Abstract
Background
Venous thromboembolism (VTE) is the third most common cause of cardiovascular illness and is projected to double in incidence by 2050. It is a spectrum of disease that includes deep venous thrombosis (DVT) and pulmonary embolism (PE). In February 2016, the American College of Chest Physicians provided updated management guidelines for DVT and PE to address some of the unresolved questions from the previous version and to provide recommendations related to newer anticoagulants.
Content
Here we review current concepts for screening, diagnosis, thromboprophylaxis, and management of DVT and PE. We also describe the management of VTE in acute, long-term, and extended phases of treatment. Thrombophilia testing is rarely necessary and should be used judiciously; the laboratory can serve an important role in preventing unnecessary testing. The direct oral anticoagulants are as effective as conventional treatment and are preferred agents except in the case of cancer. The initial management of PE should be based on risk stratification including the use of D-dimer testing. Thrombolysis is used in cases of hemodynamically unstable PE and not for low-risk patients who can be treated on an outpatient basis.
Summary
This review is intended to provide readers with updated guidelines for screening, testing, prophylaxis, and management from various organizations.
Collapse
Affiliation(s)
| | - Daniel E Sabath
- Laboratory Medicine and Medicine, University of Washington School of Medicine, Seattle, WA
| |
Collapse
|
28
|
Venous thromboembolism prophylaxis strategies for people undergoing elective total knee replacement: a systematic review and network meta-analysis. LANCET HAEMATOLOGY 2019; 6:e530-e539. [DOI: 10.1016/s2352-3026(19)30155-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 02/06/2023]
|
29
|
Seagrave KG, Fletcher JP, Hitos K. Aspirin for prevention of venous thromboembolism in recipients of major lower-limb orthopedic surgery: a systematic review of Level I evidence. INT ANGIOL 2019; 38:429-442. [PMID: 31580039 DOI: 10.23736/s0392-9590.19.04086-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Major lower-limb orthopedic surgery recipients are at increased risk of venous thromboembolism (VTE). The optimal strategy for preventing VTE is a topic of ongoing debate. The use of aspirin has been implicated in reducing VTE events and is potentially advantageous compared to other agents in respect to cost, access, route of administration and reduced adverse effects such as bleeding. EVIDENCE ACQUISITION A systematic search for Level I evidence (systematic reviews and meta-analyses of randomised-controlled trials) was performed in April 2019 to evaluate the use of aspirin for primary and secondary VTE prophylaxis compared to alternative chemical and mechanical strategies. This search encompassed three electronic databases (Pubmed, Embase and the Cochrane Database of Systematic Reviews). All references of included studies were screened for additional studies. Data was compiled and compared to the recommendations and guidelines published by major institutions. Included studies were appraised with the aid of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. EVIDENCE SYNTHESIS In total, 21 studies were included. Interventions and outcomes identified were heterogeneous across studies. Most statistical tests applied found no difference between aspirin and other interventions in regards to deep vein thrombosis, pulmonary embolism, bleeding and mortality outcomes. CONCLUSIONS Aspirin may be a viable alternative to established thromboprophylactic regimes for primary prevention of VTE, however in the setting of secondary prevention it is generally less efficacious. Future studies should have clearly identified and comparable outcome measures, with direct comparisons and assessment of intervention combination, dosing and treatment duration.
Collapse
Affiliation(s)
- Kurt G Seagrave
- The University of Sydney, Westmead Clinical School, Sydney, Australia -
| | - John P Fletcher
- The University of Sydney, Westmead Clinical School, Sydney, Australia.,Westmead Research Centre for Evaluation of Surgical Outcomes, Department of Surgery, Westmead Hospital, Sydney, Australia
| | - Kerry Hitos
- The University of Sydney, Westmead Clinical School, Sydney, Australia.,Westmead Research Centre for Evaluation of Surgical Outcomes, Department of Surgery, Westmead Hospital, Sydney, Australia
| |
Collapse
|
30
|
Kozieł M, Lip GYH. Venous thromboembolism prophylaxis strategies for patients undergoing elective total knee replacement. LANCET HAEMATOLOGY 2019; 6:e496-e497. [PMID: 31444125 DOI: 10.1016/s2352-3026(19)30164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L7 8TX, UK; Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool L7 8TX, UK; Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| |
Collapse
|
31
|
Lewis S, Glen J, Dawoud D, Dias S, Cobb J, Griffin X, Reed M, Sharpin C, Stansby G, Barry P. Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip Replacement: A Systematic Review and Network Meta-Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:953-969. [PMID: 31426937 DOI: 10.1016/j.jval.2019.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 12/22/2018] [Accepted: 02/19/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of venous thromboembolism prophylaxis in people undergoing elective total hip replacement. METHODS Systematic review and Bayesian network meta-analyses of randomized controlled trials were conducted for 3 outcomes: deep vein thrombosis (DVT), pulmonary embolism (PE), and major bleeding (MB). MEDLINE, EMBASE, and Cochrane Library (CENTRAL) databases were searched. Study quality was assessed using the Cochrane risk-of-bias checklist. Fixed- and random-effects models were fitted and compared. The median relative risk (RR) and odds ratio (OR) compared with no prophylaxis, with their 95% credible intervals (CrIs), rank, and probability of being the best, were calculated. RESULTS Forty-two (n = 24 374, 26 interventions), 30 (n = 28 842, 23 interventions), and 24 (n = 31 792, 15 interventions) randomized controlled trials were included in the DVT, PE, and MB networks, respectively. Rivaroxaban had the highest probability of being the most effective intervention for DVT (RR 0.06 [95% CrI 0.01-0.29]). Strategy of low-molecular-weight heparin followed by aspirin had the highest probability of reducing the risk of PE and MB (RR 0.0011 [95% CrI 0.00-0.096] and OR 0.37 [95% CrI 0.00-26.96], respectively). The ranking of efficacy estimates across the 3 networks, particularly PE and MB, had very wide CrIs, indicating high degree of uncertainty. CONCLUSIONS A strategy of low-molecular-weight heparin given for 10 days followed by aspirin for 28 days had the best benefit-risk balance, with the highest probability of being the best on the basis of the results of the PE and MB network meta-analyses. Nevertheless, there is considerable uncertainty around the median ranks of the interventions.
Collapse
Affiliation(s)
- Sedina Lewis
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Jessica Glen
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Dalia Dawoud
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | | | - Jill Cobb
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Xavier Griffin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael Reed
- Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | - Carlos Sharpin
- National Guideline Centre, Royal College of Physicians, London, UK
| | - Gerard Stansby
- Newcastle University and Freeman Hospital, Newcastle upon Tyne, UK
| | - Peter Barry
- University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
| |
Collapse
|
32
|
Safety of direct oral anticoagulants versus traditional anticoagulants in venous thromboembolism. J Thromb Thrombolysis 2019; 48:439-453. [DOI: 10.1007/s11239-019-01878-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
33
|
Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: Aspirin or Rivaroxaban for Venous Thromboembolism Prophylaxis After Hip or Knee Arthroplasty. Am J Phys Med Rehabil 2019; 98:e40-e42. [PMID: 30998542 DOI: 10.1097/phm.0000000000001046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
34
|
Nadi S, Vreugdenburg TD, Atukorale Y, Ma N, Maddern G, Rovers M. Safety and effectiveness of aspirin and enoxaparin for venous thromboembolism prophylaxis after total hip and knee arthroplasty: a systematic review. ANZ J Surg 2019; 89:1204-1210. [PMID: 30989803 DOI: 10.1111/ans.15122] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/22/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at risk of venous thromboembolism (VTE). Australian orthopaedic guidelines recommend aspirin and low-molecular-weight heparin (e.g. enoxaparin) for VTE prophylaxis; however, there is debate in the international literature around the use of aspirin as VTE prophylaxis. This review assesses the risks and benefits of aspirin compared to enoxaparin as VTE prophylaxis for patients undergoing THA or TKA. METHODS A systematic review was conducted to identify relevant randomized controlled trials. Studies comparing enoxaparin, aspirin and/or placebo for VTE prophylaxis in THA or TKA patients were included. Network meta-analysis (NMA) was performed to calculate risk ratios (RRs) and confidence intervals (CIs). Quality appraisal was conducted by assessing risk of bias and the strength of the evidence. RESULTS Nine randomized controlled trials were eligible for inclusion. The NMA found no statistically significant differences for the investigated outcomes: total DVT rates (RR = 1.21, 95% CI 0.86, 1.72), symptomatic pulmonary embolism (PE) rates (RR = 1.02, 95% CI 0.02, 50.86), major haemorrhage (RR = 0.97, 95% CI 0.02, 50.99) and wound complication (RR = 0.73, 95% CI 0.17, 3.20). The occurrence of PE was rare. Due to limited data, sub-group analysis was not possible. The overall quality of evidence in the NMA is considered to be very low. CONCLUSION This review did not find statistically significant differences between aspirin and enoxaparin. Future studies should identify more evidence, particularly for rare outcomes such as PE, as this might help decision-makers to get consensus on the use of aspirin as VTE prophylaxis.
Collapse
Affiliation(s)
- Sinan Nadi
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Thomas D Vreugdenburg
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Yasoba Atukorale
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Ning Ma
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Guy Maddern
- Research and Evaluation, Incorporating ASERNIP-S, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,Discipline of Surgery, The University of Adelaide and The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Maroeska Rovers
- Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| |
Collapse
|
35
|
Antiplatelet Drugs in the Management of Venous Thromboembolism, Cardioembolism, Ventricular Assist Devices, and Pregnancy Complications. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00059-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
36
|
Blin P, Samama CM, Sautet A, Benichou J, Lignot-Maleyran S, Lamarque S, Lorrain S, Lassalle R, Droz-Perroteau C, Mismetti P, Moore N. Comparative effectiveness of direct oral anticoagulants versus low-molecular weight heparins for the prevention of venous thromboembolism after total hip or knee replacement: A nationwide database cohort study. Pharmacol Res 2018; 141:201-207. [PMID: 30583081 DOI: 10.1016/j.phrs.2018.12.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) after total knee or hip replacement (TKR, THR) is usually prevented with low-molecular weight heparin (LMWH), and increasingly by direct oral anticoagulants (DOAC). The aim of the present study was to compare the benefit-risk and medical costs of DOAC vs. LMWH in a real-life setting. METHODS All patients with THR or TKR in France between Jan-1st 2013 and Sep-30th 2014, discharged to home, were identified and followed-up for 3 months in the French nationwide claims database, SNDS. DOAC users were 1:1 matched with LWMH users on gender, age and propensity score. Relative risks (RR) of hospitalized VTE, hospitalized bleeding and death were estimated using quasi-Poisson models. Medical costs were calculated according to the societal perspective, including total cost for outpatient claims and national DRG costs for hospitalisations. RESULTS Most DOAC users (≥ 98.8%) were matched to a LMWH patient. For the 63,238 matched THR patients, the 3-month absolute risk of VTE was 0.9‰ with DOAC and 2.5‰ with LMWH (RR = 0.35 [0.23 to 0.54]), of bleeding 1.8‰ and 2.1‰ (0.88 [0.62-1.25]), death 0.7‰ and 1.1‰ (0.68 [0.40-1.15]). For the 31,440 matched TKR patients, risks were 1.6‰ and 2.3‰ (0.69 [0.42-1.16]) for VTE, 2.4‰ and 3.8‰ (0.64 [0.43 to 0.97]) for bleeding, and 0.6‰ and 0.8‰ (0.69 [0.30-1.62]) for all-cause death. Mean medical costs were 28% and 21% lower with DOAC than LMWH for THR and TKR, respectively. This nationwide study found a very low risk of VTE, hospitalized bleeding and death after THR or TKR discharge in patients with VTE prevention in real-life setting, with better benefit-risk profiles of DOAC compared to LMWH, and associated cost savings.
Collapse
Affiliation(s)
- Patrick Blin
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux University, 33076, Bordeaux, France.
| | - Charles-Marc Samama
- Cochin University Hospital, Paris Descartes University, Paris, 75014, France
| | - Alain Sautet
- Saint-Antoine University Hospital, Paris, 75010, France
| | | | | | - Stéphanie Lamarque
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux University, 33076, Bordeaux, France
| | - Simon Lorrain
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux University, 33076, Bordeaux, France
| | - Régis Lassalle
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux University, 33076, Bordeaux, France
| | | | | | - Nicholas Moore
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux University, 33076, Bordeaux, France; INSERM U1219, Bordeaux, 33076, France
| |
Collapse
|
37
|
Lindquist DE, Stewart DW, Brewster A, Waldroup C, Odle BL, Burchette JE, El-Bazouni H. Comparison of Postoperative Bleeding in Total Hip and Knee Arthroplasty Patients Receiving Rivaroxaban, Enoxaparin, or Aspirin for Thromboprophylaxis. Clin Appl Thromb Hemost 2018; 24:1315-1321. [PMID: 29716395 PMCID: PMC6714764 DOI: 10.1177/1076029618772337] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Guidelines recommend the use of multiple pharmacologic agents and/or mechanical
compressive devices for prevention of venous thromboembolism, but preference for any
specific agent is no longer given in regard to safety or efficacy. Objective: To compare postoperative bleeding rates in patients receiving enoxaparin, rivaroxaban,
or aspirin for thromboprophylaxis after undergoing elective total hip arthroplasty or
total knee arthroplasty. Methods: This retrospective cohort analysis evaluated patients who received thromboprophylaxis
with either enoxaparin, rivaroxaban, or aspirin. All data were collected from the
electronic medical record. The primary outcome was any postoperative bleeding. Results: A total of 1244 patients were included with 366 in the aspirin, 438 in the enoxaparin,
and 440 in the rivaroxaban arms. Those who received aspirin or enoxaparin were less
likely to experience any bleeding compared to those patients who received rivaroxaban
(P < .05). There was also a lower rate of major bleeding in these
groups, but the differences were not significant. Conclusions: Aspirin and enoxaparin conferred similar bleeding risks, and both exhibited less
bleeding than patients who received rivaroxaban.
Collapse
Affiliation(s)
- Desirae E Lindquist
- 1 Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA
| | - David W Stewart
- 2 Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Aaryn Brewster
- 3 Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Caitlin Waldroup
- 3 Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Brian L Odle
- 2 Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Jessica E Burchette
- 2 Department of Pharmacy Practice, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN, USA
| | - Hadi El-Bazouni
- 4 Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| |
Collapse
|
38
|
Childers CP, Siletz AE, Singer ES, Faltermeier C, Hu QL, Ko CY, Golladay GJ, Kates SL, Wick EC, Maggard-Gibbons M. Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. Geriatr Orthop Surg Rehabil 2018; 9:2151458518754451. [PMID: 29468091 PMCID: PMC5813847 DOI: 10.1177/2151458518754451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 11/30/2017] [Accepted: 12/28/2017] [Indexed: 12/12/2022] Open
Abstract
Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study Design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.
Collapse
Affiliation(s)
| | - Anaar E Siletz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Emily S Singer
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Q Lina Hu
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Clifford Y Ko
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA
| | | |
Collapse
|
39
|
Garfinkel JH, Gladnick BP, Roland N, Romness DW. Increased Incidence of Bleeding and Wound Complications With Factor-Xa Inhibitors After Total Joint Arthroplasty. J Arthroplasty 2018; 33:533-536. [PMID: 28947374 DOI: 10.1016/j.arth.2017.08.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/12/2017] [Accepted: 08/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Factor-Xa inhibitors have been introduced for prevention of venous thromboembolism (VTE) after joint arthroplasty. However, these agents could also be associated with bleeding or wound complications after surgery. METHODS We retrospectively reviewed a consecutive series of 59 patients (31 knees, 28 hips) undergoing joint arthroplasty at a high-volume joint arthroplasty referral center, both before and after implementation of a new VTE risk-stratification tool at our institution. Patients with a history of VTE, bilateral procedures, or medical conditions already requiring VTE chemoprophylaxis were excluded. We reviewed the medical records to determine (1) type of VTE prophylaxis used, (2) incidence of bleeding/wound complications in the postoperative period, (3) incidence of VTE in the postoperative period, and (4) change in serum hemoglobin. RESULTS Twenty-seven patients (46%) were given aspirin for VTE prophylaxis, while 32 patients (54%) received a factor-Xa inhibitor. There were no new VTE complications in either group. And 6 of 32 patients (18.7%) in the Xa inhibitor group had a postoperative bleeding/wound complication (4 delayed healing/blistering, 1 hematoma/excessive ecchymosis, and 1 readmission for cellulitis). There were no (0%) bleeding/wound complications in the aspirin group (P = .03). The change in hemoglobin level was -2.76 g/dL in patients receiving aspirin vs -2.84 g/dL in patients receiving a Xa inhibitor (P = .73). CONCLUSION In our study of total joint patients, factor-Xa inhibitors were associated with a higher incidence of bleeding/wound complications. The choice of VTE prophylaxis should be based on the perceived risks of bleeding and wound complications compared to the risks of VTE in each patient.
Collapse
Affiliation(s)
| | - Brian P Gladnick
- OrthoVirginia, Adult Hip and Knee Reconstruction, Arlington, Virginia; Virginia Hospital Center, Arlington, Virginia
| | | | - David W Romness
- OrthoVirginia, Adult Hip and Knee Reconstruction, Arlington, Virginia; Virginia Hospital Center, Arlington, Virginia
| |
Collapse
|
40
|
Hur M, Park SK, Koo CH, Jung ED, Kang P, Kim WH, Kim JT, Jung CW, Bahk JH. Comparative efficacy and safety of anticoagulants for prevention of venous thromboembolism after hip and knee arthroplasty. Acta Orthop 2017; 88:634-641. [PMID: 28787226 PMCID: PMC5694808 DOI: 10.1080/17453674.2017.1361131] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - New oral anticoagulants have been developed to prevent venous thromboembolism (VTE) after knee or hip arthroplasty. Although there have been several network meta-analyses (NMA) to compare different regimens, an NMA including 2 different enoxaparin doses and edoxaban has not been performed. Methods - Standard NMA for fondaparinux, dabigatran, rivaroxaban, apixaban, edoxaban, and enoxaparin was performed. Outcome variables included a composite of total VTE and major/clinically relevant bleeding. The rank probabilities of each treatment outcome were summarized by the surface under the cumulative ranking curve. Results - Fondaparinux, rivaroxaban, and apixaban were associated with a reduced risk of VTE compared with enoxaparin, while dabigatran was not. None of these 3 drugs increased bleeding compared with enoxaparin 30 mg twice daily. However, fondaparinux and rivaroxaban increased bleeding compared with enoxaparin 40 mg once daily, while apixaban did not. Apixaban was even associated with decreased major/clinically relevant bleeding compared with enoxaparin 30 mg twice daily or 40 mg once daily. When edoxaban was included in the NMA, edoxaban decreased VTE and did not increase bleeding compared with enoxaparin. Interpretation - A higher efficacy of fondaparinux and rivaroxaban compared with enoxaparin was associated with increased bleeding tendency, while apixaban was superior to enoxaparin regarding both efficacy and safety. A clustered ranking plot showed that apixaban might be the most preferred regarding efficacy and safety. However, our results were driven by indirect statistical inference and were limited by the heterogeneity of the bleeding outcome definitions, drug initiation and continuation, and different surgery types.
Collapse
|