Eikelboom John W, Karthikeyan Ganesan, Fagel Nick, Hirsh Jack
Department of Medicine, McMaster University, all located in Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, all located in Hamilton, ON, Canada; Thrombosis Service, Hamilton General Hospital, McMaster University, all located in Hamilton, ON, Canada.
Department of Medicine, McMaster University, all located in Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences and McMaster University, all located in Hamilton, ON, Canada.
Chest. 2009 Feb;135(2):513-520. doi: 10.1378/chest.08-2655.
The recently published American Association of Orthopedic Surgeons (AAOS) guidelines for the prevention of venous thromboembolism (VTE) in patients undergoing hip or knee surgery conflict with long-established and widely used American College of Chest Physicians (ACCP) guidelines. Both guidelines accepted that the most important goal of thromboprophylaxis in patients undergoing hip or knee replacement is to prevent pulmonary embolism (PE). The ACCP guidelines included asymptomatic (and symptomatic) deep vein thrombosis (DVT) detected by venography as a measure of the efficacy of thromboprophylaxis, whereas the AAOS rejected DVT as a valid outcome because the panelists considered the link between DVT and PE to be unproven. The AAOS position is inconsistent with evidence from imaging studies linking DVT with PE and from clinical studies demonstrating a parallel reduction of DVT and PE when antithrombotic agents are compared with placebo or untreated controls. The AAOS panel ignored the randomized data demonstrating that thromboprophylaxis reduces both DVT and PE, and many of their recommendations are based on expert opinion and lack a scientific basis. We recommend the ACCP guidelines because the methodology is explicit and rigorous and the treatment recommendations reflect all of the evidence from the randomized trials. Adoption of the ACCP guideline will ensure that patients undergoing hip and knee arthroplasty receive the best available therapies for prevention of VTE and reduce disability and death due to this common and potentially preventable condition.
美国矫形外科医师协会（AAOS）近期发布的关于髋或膝关节手术患者预防静脉血栓栓塞（VTE）的指南，与长期确立且广泛使用的美国胸科医师学会（ACCP）指南相冲突。这两份指南都认同，髋或膝关节置换患者血栓预防的最重要目标是预防肺栓塞（PE）。ACCP指南将通过静脉造影检测到的无症状（及有症状）深静脉血栓形成（DVT）纳入作为血栓预防疗效的一项衡量指标，而AAOS则不将DVT视为有效结局，因为专家小组成员认为DVT与PE之间的关联未经证实。AAOS的立场与影像学研究中将DVT与PE相联系的证据以及临床研究中显示当抗血栓药物与安慰剂或未治疗对照进行比较时DVT和PE同时减少的证据不一致。AAOS专家小组忽视了表明血栓预防可降低DVT和PE的随机数据，其许多建议基于专家意见且缺乏科学依据。我们推荐ACCP指南，因为其方法明确且严谨，治疗建议反映了来自随机试验的所有证据。采用ACCP指南将确保接受髋和膝关节置换术的患者获得预防VTE的最佳可用疗法，并减少因这种常见且可能可预防的病症导致的残疾和死亡。
