Douketis James D, Eikelboom John W, Quinlan Daniel J, Willan Andrew R, Crowther Mark A
Department of Medicine, McMaster University, and St Joseph's Hospital, Hamilton, Ontario, Canada L8N 4A6.
Arch Intern Med. 2002 Jul 8;162(13):1465-71. doi: 10.1001/archinte.162.13.1465.
The prevalence of asymptomatic deep vein thrombosis diagnosed by venography after hip or knee replacement remains high despite 7 to 10 days of anticoagulant prophylaxis. However, the risk of symptomatic events in such patients is unclear. We performed a meta-analysis to provide reliable estimates of the risk of symptomatic venous thromboembolism occurring within 3 months of hip or knee replacement in patients who received short-duration (7-10 days) anticoagulant prophylaxis.
The MEDLINE, EMBASE, and Cochrane databases were searched from January 1993 to March 2001, supplemented by a manual search of bibliographies and conference abstracts, to identify prospective studies of patients undergoing hip or knee replacement who received short-duration prophylaxis (ie, 7-10 days of fixed-dose low-molecular-weight heparin or adjusted-dose warfarin, with a target international normalized ratio of 2.0-3.0). Studies were classified as clinical outcome studies if the outcome was symptomatic venous thromboembolism or as venographic outcome studies if the outcome was asymptomatic deep vein thrombosis diagnosed after bilateral venography.
There were 4 clinical outcome studies with 6089 patients who had 3 months of follow-up, and 13 venographic outcome studies with 7080 patients who had venography 7 to 10 days after surgery. In clinical outcome studies, the 3-month incidence of nonfatal venous thromboembolism was 3.2% (95% confidence interval [CI], 2.0%-4.4%), and the 3-month incidence of fatal pulmonary embolism was 0.10% (95% CI, 0.02%-0.20%). The postprophylaxis incidence of nonfatal venous thromboembolism was 2.2% (95% CI, 1.4%-3.0%), and the incidence of fatal pulmonary embolism was 0.05% (95% CI, 0%-0.12%). The postprophylaxis incidence of symptomatic venous thromboembolism was higher after hip than after knee replacement (2.5% vs 1.4%; P=.02). In venographic outcome studies, the prevalence of deep vein thrombosis (total and proximal) was higher after knee than after hip replacement (total: 38.8% vs 16.4%; P<.001; proximal: 7.6% vs 3.8%; P<.001).
In patients who undergo hip or knee replacement and receive short-duration anticoagulant prophylaxis, symptomatic nonfatal venous thromboembolism will occur in about 1 of 32 patients and fatal pulmonary embolism will occur in about 1 of 1000 patients within 3 months of the surgery. Although the prevalence of asymptomatic deep vein thrombosis is more than 2-fold higher after knee replacement than after hip replacement 7 to 10 days after surgery, in the subsequent 3 months, symptomatic venous thromboembolism is more likely to occur after hip replacement.
尽管进行了7至10天的抗凝预防，但通过静脉造影诊断出的髋关节或膝关节置换术后无症状深静脉血栓形成的发生率仍然很高。然而，此类患者发生有症状事件的风险尚不清楚。我们进行了一项荟萃分析，以提供在接受短期（7 - 10天）抗凝预防的患者中，髋关节或膝关节置换术后3个月内发生有症状静脉血栓栓塞风险的可靠估计。
检索了1993年1月至2001年3月的MEDLINE、EMBASE和Cochrane数据库，并通过手动检索参考文献和会议摘要进行补充，以确定接受短期预防（即7 - 10天固定剂量低分子量肝素或调整剂量华法林，目标国际标准化比值为2.0 - 3.0）的髋关节或膝关节置换患者的前瞻性研究。如果结果是有症状静脉血栓栓塞，则将研究分类为临床结局研究；如果结果是双侧静脉造影后诊断出的无症状深静脉血栓形成，则分类为静脉造影结局研究。
有4项临床结局研究，共6089例患者，随访3个月；有13项静脉造影结局研究，共7080例患者，在术后7至10天进行静脉造影。在临床结局研究中，非致命性静脉血栓栓塞的3个月发生率为3.2%（95%置信区间[CI]，2.0% - 4.4%），致命性肺栓塞的3个月发生率为0.10%（95% CI，0.02% - 0.20%）。预防后非致命性静脉血栓栓塞的发生率为2.2%（95% CI，1.4% - 3.0%），致命性肺栓塞的发生率为0.05%（95% CI，0% - 0.12%）。髋关节置换后预防后有症状静脉血栓栓塞的发生率高于膝关节置换（2.5%对1.4%；P = 0.02）。在静脉造影结局研究中，膝关节置换后深静脉血栓形成（总体和近端）的发生率高于髋关节置换（总体：38.8%对16.4%；P < 0.001；近端：7.6%对3.8%；P < 0.001）。
在接受髋关节或膝关节置换并接受短期抗凝预防的患者中，在手术后3个月内，约32名患者中会有1名发生有症状的非致命性静脉血栓栓塞，约1000名患者中会有1名发生致命性肺栓塞。尽管膝关节置换术后7至10天无症状深静脉血栓形成的发生率比髋关节置换术后高2倍多，但在随后的3个月内，髋关节置换后更有可能发生有症状的静脉血栓栓塞。
