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Roberts LN, Arya R, Hunt BJ. Advances and current research in primary thromboprophylaxis to prevent hospital-associated venous thromboembolism. Br J Haematol 2024; 204:1635-1648. [PMID: 38577829 DOI: 10.1111/bjh.19424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
Hospital-associated venous thromboembolism (VTE) is defined as any case of VTE occurring during hospital admission and for up to 90 days post discharge. It accounts for over 50% of all cases of VTE internationally; indeed, there are an estimated 10 million cases of hospital-associated VTE annually. Over the last decade, there has been increasing interest in improving VTE risk assessment and thromboprophylaxis. This review summarises all the recent and ongoing major research studies and future challenges in the different areas, including medical, surgical and obstetric patients, as well as special areas such as lower limb immobilisation. We include sections on both pharmacological and mechanical thromboprophylaxis.
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Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, London, UK
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Moore MC, Dubin JA, Bains SS, Hameed D, Nace J, Delanois RE. Trends in deep vein thrombosis prophylaxis after total hip arthroplasty: 2016 to 2021. J Orthop 2024; 48:77-83. [PMID: 38059214 PMCID: PMC10696429 DOI: 10.1016/j.jor.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/12/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Venous thromboembolism (VTE) has long been acknowledged as a potential complication of total hip arthroplasty (THA) contributing to heightened patient morbidity, mortality, and substantial healthcare costs. We aimed to: 1) assess trends in VTE prophylaxis utilization between 2016 and 2021; 2) determine the incidence of postoperative VTE and transfusions; and 3) identify independent risk factors for 90-day VTE and transfusion risks following THA in relation to the use of aspirin, dabigatran, enoxaparin, rivaroxaban, and warfarin. Methods A national, all-payer database was queried from January 1, 2016 and December 31, 2022. Use trends for aspirin, enoxaparin, rivaroxaban, dabigatran, and warfarin as thromboprophylaxis following THA was assessed. Incidence of ninety-day postoperative outcomes assessed included rates of 90-day postoperative VTE and transfusion. Results From 2016 to 2021, aspirin (n = 36,346) was the most used agent for VTE prophylaxis after THA, followed by dabigatran (n = 13,065), rivaroxaban (n = 11,790), enoxaparin (n = 11,380), and warfarin (n = 6326). Independent risk factors for 90-day VTE included CKD, COPD, CHF, obesity, dabigatran, enoxaparin, rivaroxaban, and warfarin (all p < 0.05). Conclusion Aspirin was used with increasing frequency and demonstrated lower rates of VTE and transfusion following THA, compared to dabigatran, enoxaparin, rivaroxaban, and warfarin. These findings seem to indicate that the increasing use of aspirin in VTE prophylaxis has been accomplished in appropriately selected patients.
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Affiliation(s)
- Mallory C. Moore
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A. Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Sandeep S. Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ronald E. Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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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.
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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
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Nelson CL. CORR Insights®: Are Patients With Morbid Obesity at Increased Risk of Pulmonary Embolism or Proximal Deep Vein Thrombosis After Lower Limb Arthroplasty? A Large-database Study. Clin Orthop Relat Res 2023; 482:00003086-990000000-01333. [PMID: 37669543 PMCID: PMC10723887 DOI: 10.1097/corr.0000000000002833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/28/2023] [Indexed: 09/07/2023]
Affiliation(s)
- Charles L Nelson
- Professor of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Ye L, Xie H, Lai M, Zheng G, Xie Y, Liu X. Risk factors for patients with acute hospital-acquired symptomatic pulmonary thromboembolism. Sci Rep 2023; 13:7552. [PMID: 37160945 PMCID: PMC10169767 DOI: 10.1038/s41598-023-34589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023] Open
Abstract
This study aimed to identify independent risk factors for acute hospital-acquired symptomatic pulmonary embolism (HA-SPE) by comparing the clinical data of HA-SPE and acute nonhospital-acquired symptomatic pulmonary embolism (NHA-SPE). A total of 292 patients were included in the analysis and divided into two groups: 191 patients had acute NHA-SPE, and 101 patients had acute HA-SPE. The average age of these 292 patients was 63.2 years, and the sample included 145 males. Multivariate analysis showed that malignant tumour (OR, 3.811; 95% CI [1.914-7.586], P = 0.000), recent surgery (OR, 7.310; 95% CI 3.392-15.755], P = 0.000), previous VTE (OR, 5.973; 95% CI 2.194 16.262], P = 0. 000), and the length of stay (LOS) (OR, 1.075; 95% CI [1.040-1.111], P = 0.000) were independent risk factors for acute HA-AEP. The c-statistic for this model was 0.758 (95% CI [0.698-0.800], P < 0.0001). The K-M curve showed that the hazard ratio (HR) of the HA group to the NHA group in all-cause mortality was 3.807 (95% CI [1.987, 7.295], P = 0.0061). Strengthening the prevention and control of patients with these risk factors may reduce the incidence of acute HA-SPE.
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Affiliation(s)
- Lujuan Ye
- The Department of General Surgery, Ganzhou People's Hospital, Ganzho, 341000, Jiangxi, People's Republic of China
| | - Hailiang Xie
- The Department of General Surgery, Ganzhou People's Hospital, Ganzho, 341000, Jiangxi, People's Republic of China
| | - Minggui Lai
- The Department of General Surgery, Ganzhou People's Hospital, Ganzho, 341000, Jiangxi, People's Republic of China
| | - Guofu Zheng
- The Department of General Surgery, Ganzhou People's Hospital, Ganzho, 341000, Jiangxi, People's Republic of China
| | - Yuancai Xie
- The Department of General Surgery, Ganzhou People's Hospital, Ganzho, 341000, Jiangxi, People's Republic of China
| | - Xiaochun Liu
- The Department of General Surgery, Ganzhou People's Hospital, Ganzho, 341000, Jiangxi, People's Republic of China.
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Zhang LK, Li Q, Fang YF, Qi JW. Effect of duloxetine on pain relief after total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2023; 102:e33101. [PMID: 36897714 PMCID: PMC9997837 DOI: 10.1097/md.0000000000033101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/06/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Postoperative pain is one of the most feared complications of total knee arthroplasty. Recently, randomized controlled trials have compared the efficacy of duloxetine in patients undergoing total knee arthroplasty. However, there is no definite answer as to the efficacy and safety of duloxetine. METHODS Randomized controlled trials about relevant studies were searched from PubMed (1996 to July 2022), Embase (1996 to July 2022), and Cochrane Library (CENTRAL, July 2022). RESULTS Six high-quality studies containing 532 patients met the inclusion criteria. Results show patients in the duloxetine group had better performance in terms of visual analog scale (P < .05), equivalent morphine consumption (P < .05), and length of stay (P < .05). CONCLUSION Duloxetine can be used to reduce pain after knee arthroplasty in selected patients.
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Affiliation(s)
- Lu-Kai Zhang
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Qiang Li
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Yan-Fen Fang
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Ji-Wei Qi
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
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Piple AS, Wang JC, Kang HP, Mills ES, Mayfield CK, Lieberman JR, Christ AB, Heckmann ND. Safety and Efficacy of Rivaroxaban in Primary Total Hip and Knee Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00137-7. [PMID: 36805121 DOI: 10.1016/j.arth.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND An optimal venous thromboembolism prophylaxis agent should balance efficacy and safety. While rivaroxaban provides effective venous thromboembolism prophylaxis after total joint arthroplasty, it may be associated with higher rates of bleeding. This study aimed to compare the safety and efficacy of rivaroxaban to aspirin and enoxaparin. METHODS A large national database was queried for patients who underwent elective primary total hip (THA) or total knee arthroplasty (TKA) from January 2015 through December 2020 who received rivaroxaban, aspirin, or enoxaparin. Multivariate analyses were performed to assess the 90-day risk of bleeding and thromboembolic complications. Among TKA patients identified, 86,721 (10.8%) received rivaroxaban, 408,038 (50.8%) received aspirin, and 108,377 (13.5%) received enoxaparin. Among THA patients, 42,469 (9.5%) received rivaroxaban, 242,876 (54.5%) received aspirin, and 59,727 (13.4%) received enoxaparin. RESULTS After accounting for confounding factors, rivaroxaban was associated with increased risk of transfusion (TKA: adjusted odds ratio [aOR] = 2.58, P < .001; THA: aOR 1.64, P < .001), pulmonary embolism (TKA: aOR = 1.25, P = .007), and deep vein thrombosis (TKA: aOR = 1.13, P = .022) compared to aspirin. Compared to enoxaparin, rivaroxaban was associated with an increased risk of combined bleeding events (TKA: aOR = 1.07, P < .001, THA: aOR = 1.11, P < .001), but decreased risk of combined prothrombotic events (THA: aOR = 0.85, P = .036). CONCLUSION Rivaroxaban chemoprophylaxis following TKA and THA was associated with an increased risk of bleeding and prothrombotic complications compared to aspirin and enoxaparin.
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Affiliation(s)
- Amit S Piple
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jennifer C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Hyunwoo P Kang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Emily S Mills
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Cory K Mayfield
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Alexander B Christ
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Chan NC, Bhandari M. Thromboprophylaxis After Hip or Knee Arthroplasty. JAMA 2022; 328:712-713. [PMID: 35997752 DOI: 10.1001/jama.2022.11249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Noel C Chan
- Population Health Research Institute, Hamilton, Ontario, Canada
- Thrombosis Service, Department of Medicine, Hamilton General Hospital and McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Pellegrini VD, Eikelboom JW, Evarts CM, Franklin PD, Garvin KL, Goldhaber SZ, Iorio R, Lambourne CA, Magaziner J, Magder L. Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol. BMJ Open 2022; 12:e060000. [PMID: 35260464 PMCID: PMC8905949 DOI: 10.1136/bmjopen-2021-060000] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION More than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%-0.5% fatal PE, and over 1000 deaths. Antithrombotic prophylaxis is standard of care but evidence is limited and conflicting. We will compare effectiveness of three commonly used chemoprophylaxis agents to prevent all-cause mortality (ACM) and clinical venous thromboembolism (VTE) while avoiding bleeding complications. METHODS AND ANALYSIS Pulmonary Embolism Prevention after HiP and KneE Replacement is a large randomised pragmatic comparative effectiveness trial with non-inferiority design and target enrolment of 20 000 patients comparing aspirin (81 mg two times a day), low-intensity warfarin (INR (International Normalized Ratio) target 1.7-2.2) and rivaroxaban (10 mg/day). The primary effectiveness outcome is aggregate of VTE and ACM, primary safety outcome is clinical bleeding complications, and patient-reported outcomes are determined at 1, 3 and 6 months. Primary data analysis is per protocol, as preferred for non-inferiority trials, with secondary analyses adherent to intention-to-treat principles. All non-fatal outcomes are captured from patient and clinical reports with independent blinded adjudication. Study design and oversight are by a multidisciplinary stakeholder team including a 10-patient advisory board. ETHICS AND DISSEMINATION The Institutional Review Board of the Medical University of South Carolina provides central regulatory oversight. Patients aged 21 or older undergoing primary or revision hip or knee replacement are block randomised by site and procedure; those on chronic anticoagulation are excluded. Recruitment commenced at 30 North American centres in December 2016. Enrolment currently exceeds 13 500 patients, representing 33% of those eligible at participating sites, and is projected to conclude in July 2024; COVID-19 may force an extension. Results will inform antithrombotic choice by patients and other stakeholders for various risk cohorts, and will be disseminated through academic publications, meeting presentations and communications to advocacy groups and patient participants. TRIAL REGISTRATION NCT02810704.
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Affiliation(s)
| | | | - C McCollister Evarts
- Orthopaedics and Physical Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin L Garvin
- Orthopaedics and Physical Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Richard Iorio
- Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carol Ann Lambourne
- Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jay Magaziner
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence Magder
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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