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Systemic review finds that potent
anticoagulants increase the risk of mortality after THA,
TKA
April 2008
Using potent anticoagulants such as low-molecular-weight heparin
to prevent pulmonary embolism in total hip or knee arthroplasty
patients, as recommended by the Chest Physicians Consensus
Statement, may actually increase the risk of all-cause mortality
compared to multimodal prophylaxis measures, according to a
systematic literature review published in Clinical Orthopaedics
and Related Research.
"We believe the American College of Chest Physicians should
reconsider their guidelines to reflect the fact that PE
(pulmonary embolism) occurs despite the use of potent
anticoagulants and may, in fact, expose patients to increased
mortality after surgery," the authors said in the
study.
Nigel E. Sharrock, BMedSci, MB, ChB, and colleagues at the
Hospital for Special Surgery, New York, conducted the systematic
review, which included 20 English language studies published
during the last 9 years. The researchers focused on studies that
involved patients undergoing total hip arthroplasty (THA) or
total knee arthroplasty (TKA) and divided publications into three
categories based on the venous thromboembolism prophylaxis
regimen.
Specifically, Group A included the use of low-molecular-weight
heparin, ximelagatran, fondaparinux or rivaroxaban, Group B
included the use of a multimodal prophylaxis, and Group C
included the use of warfarin.
"Multimodal prophylaxis (Group B) was defined as a protocol
consisting of intention to use regional anesthesia (epidural or
spinal) with or without intraoperative heparin during surgery or
pneumatic compression and aspirin after surgery," the study
authors noted.
The researchers found that the lowest number of deaths occurred
among patients in Group B. Patients in Groups A and C were more
than two times as likely to die compared to those in Group B,
with no significant difference between Group A and Group C.
Patients in Group A also had a 60% to 70% higher risk of nonfatal
PE compared to patients in Group B.
Nonfatal PE occurred in 94 of 15,839 patients in Group A (0.6%)
vs. 25 of 7,193 patients in Group B (0.35%), according to the
study.
"We show clinical PE occurs despite the use of powerful
anticoagulants. The rate of 0.6% is comparable to the rate of 1%
previously described with warfarin and low-molecular-weight
heparin in cohort studies.
"This literature cannot support the use of powerful
anticoagulants to prevent PE, although they clearly reduce the
risk of venographically evident deep vein thrombosis," the
study authors wrote.
For more information:
Sharrock NE, Gonzalez Della Valle A, Go G, et al. Potent
anticoagulants are associated with a higher all-cause mortality
rate after hip and knee arthroplasty. Clin Orthop Relat Res.
2008;466:714-721.
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