University of California-Davis Medical Center, Sacramento, CA, USA.
Ann Pharmacother. 2012 Jan;46(1):79-88. doi: 10.1345/aph.1P626. Epub 2011 Dec 27.
BACKGROUND: Guidelines for the prevention of venous thromboembolism (VTE) after elective total hip or knee arthroplasty (THA/TKA) have been developed separately by the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Differences exist in approaches to preventing postoperative VTE through prophylaxis. OBJECTIVE: To compare trials using vitamin K antagonists (VKAs) and differences in guidelines to determine the benefits and drawbacks of warfarin for VTE prophylaxis following THA/TKA. DATA SOURCES: Guidelines from the AAOS published in 2009 and revised in 2011 and from the ACCP published in 2008 were compared for recommendations on the use of VKAs. A MEDLINE search from 1960 to November 2009 was conducted to identify pertinent articles on the use of warfarin or VKAs for VTE prophylaxis following THA/TKA. Search terms included warfarin, vitamin K antagonist, total hip or total knee replacement, and total hip or total knee arthroplasty. STUDY SELECTION AND DATA EXTRACTION: Only clinical trials in which warfarin was the primary agent for prophylaxis compared to other anticoagulants were included. DATA SYNTHESIS: Data on differences between guideline recommendations for the use of VKAs and the importance of a deep vein thrombosis or asymptomatic events were extracted. Thirteen comparative trials using VKAs for VTE prophylaxis and international normalized ratio (INR) targets were assessed. Overall, the incidence of bleeding tended to be lower with the use of VKAs, but thrombosis when including asymptomatic events was numerically higher when comparing INR targets. However, INR targets varied, with no comparative trials assessing the AAOS 2009 recommended INR target of 1.5-2.0. The AAOS guidelines initially recommended a longer duration of therapy and expressed stronger support for the use of aspirin for prophylaxis; however, in 2011, its guidelines were revised, with no specific recommendations as to agent, dose, or INR target goal. CONCLUSIONS: Warfarin is an effective agent to prevent VTE after elective THA/TKA. The most effective approach, including extended warfarin use up to 4 weeks or longer, has not been determined.
背景：美国骨科医师学会（AAOS）和美国胸科医师学会（ACCP）分别制定了择期全髋关节或膝关节置换术（THA/TKA）后预防静脉血栓栓塞症（VTE）的指南。在预防术后 VTE 方面，通过预防措施，两种方法存在差异。 目的：比较使用维生素 K 拮抗剂（VKA）的试验和指南之间的差异，以确定华法林在 THA/TKA 后预防 VTE 的利弊。 数据来源：比较了 AAOS 分别于 2009 年和 2011 年发布、ACCP 于 2008 年发布的指南中关于 VKA 使用的建议。从 1960 年到 2009 年 11 月，进行了 MEDLINE 检索，以确定有关华法林或 VKA 用于 THA/TKA 后 VTE 预防的文章。检索词包括华法林、维生素 K 拮抗剂、全髋关节或全膝关节置换术和全髋关节或全膝关节置换术。 研究选择和数据提取：仅纳入将华法林作为主要预防药物与其他抗凝剂进行比较的临床试验。 数据综合：提取了指南推荐使用 VKA 之间的差异数据以及深静脉血栓形成或无症状事件的重要性数据。评估了 13 项使用 VKA 进行 VTE 预防和国际标准化比值（INR）目标的比较试验。总体而言，使用 VKA 出血的发生率较低，但比较 INR 目标时，包括无症状事件的血栓形成发生率较高。然而，INR 目标存在差异，没有比较试验评估 AAOS 2009 年推荐的 INR 目标 1.5-2.0。AAOS 指南最初推荐更长的治疗时间，并更强烈地支持使用阿司匹林进行预防；然而，在 2011 年，其指南进行了修订，没有具体建议使用何种药物、剂量或 INR 目标。 结论：华法林是预防择期 THA/TKA 后 VTE 的有效药物。尚未确定最有效的方法，包括延长华法林使用时间长达 4 周或更长时间。
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