Research Department, New England Baptist Hospital, Boston, Massachusetts.
Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
JAMA Netw Open. 2023 Dec 1;6(12):e2345883. doi: 10.1001/jamanetworkopen.2023.45883.
The optimal pharmacologic thromboprophylaxis agent after total hip and total knee arthroplasty is uncertain and consensus is lacking. Quantifying the risk of postoperative venous thromboembolism (VTE) and bleeding and evaluating comparative effectiveness and safety of the thromboprophylaxis strategies can inform care.
To quantify risk factors for postoperative VTE and bleeding and compare patient outcomes among pharmacological thromboprophylaxis agents used after total hip and knee arthroplasty.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from a large health care claims database. Participants included patients in the United States with hip or knee arthroplasty and continuous insurance enrollment 3 months prior to and following their surgical procedure. Patients were excluded if they received anticoagulation before surgery, received no postsurgical pharmacological thromboprophylaxis, or had multiple postsurgery thromboprophylactic agents. In a propensity-matched analysis, patients receiving a direct oral anticoagulant (DOAC) were matched with those receiving aspirin.
Aspirin, apixaban, rivaroxaban, enoxaparin, or warfarin.
The primary outcome was 30-day cumulative incidence of postdischarge VTE. Other outcomes included postdischarge bleeding.
Among 29 264 patients included in the final cohort, 17 040 (58.2%) were female, 27 897 (95.2%) had inpatient admissions with median (IQR) length of stay of 2 (1-2) days, 10 948 (37.4%) underwent total hip arthroplasty, 18 316 (62.6%) underwent total knee arthroplasty; and median (IQR) age was 59 (55-63) years. At 30 days, cumulative incidence of VTE was 1.19% (95% CI, 1.06%-1.32%) and cumulative incidence of bleeding was 3.43% (95% CI, 3.22%-3.64%). In the multivariate analysis, leading risk factors associated with increased VTE risk included prior VTE history (odds ratio [OR], 5.94 [95% CI, 4.29-8.24]), a hereditary hypercoagulable state (OR, 2.64 [95% CI, 1.32-5.28]), knee arthroplasty (OR, 1.65 [95% CI, 1.29-2.10]), and male sex (OR, 1.34 [95% CI, 1.08-1.67]). In a propensity-matched cohort of 7844 DOAC-aspirin pairs, there was no significant difference in the risk of VTE in the first 30 days after the surgical procedure (OR, 1.14 [95% CI, 0.82-1.59]), but postoperative bleeding was more frequent in patients receiving DOACs (OR, 1.36 [95% CI, 1.13-1.62]).
In this cohort study of patients who underwent total hip or total knee arthroplasty, underlying patient risk factors, but not choice of aspirin or DOAC, were associated with postsurgical VTE. Postoperative bleeding rates were lower in patients prescribed aspirin. These results suggest that thromboprophylaxis strategies should be patient-centric and tailored to individual risk of thrombosis and bleeding.
全髋关节和全膝关节置换术后最佳的药物性血栓预防药物尚不确定，也缺乏共识。量化术后静脉血栓栓塞症（VTE）和出血的风险，并评估血栓预防策略的比较效果和安全性，可以为临床决策提供依据。
量化全髋关节和全膝关节置换术后 VTE 和出血的风险因素，并比较使用的药物性血栓预防药物的患者结局。
设计、地点和参与者：这是一项回顾性队列研究，使用了来自大型医疗保健索赔数据库的数据。参与者包括在美国接受髋关节或膝关节置换术且在手术前后连续三个月有保险的患者。如果患者在手术前接受抗凝治疗、术后未接受任何药物性血栓预防或接受了多种术后预防血栓药物，则将其排除。在倾向评分匹配分析中，接受直接口服抗凝剂（DOAC）的患者与接受阿司匹林的患者进行匹配。
阿司匹林、阿哌沙班、利伐沙班、依诺肝素或华法林。
主要结局是术后 30 天累积的 VTE 发生率。其他结局包括术后出血。
在最终队列的 29264 例患者中，17040 例（58.2%）为女性，27897 例（95.2%）为住院患者，中位（IQR）住院时间为 2（1-2）天，10948 例（37.4%）接受全髋关节置换术，18316 例（62.6%）接受全膝关节置换术；中位（IQR）年龄为 59（55-63）岁。在 30 天内，VTE 的累积发生率为 1.19%（95%CI，1.06%-1.32%），出血的累积发生率为 3.43%（95%CI，3.22%-3.64%）。多变量分析显示，与 VTE 风险增加相关的主要危险因素包括既往 VTE 病史（比值比[OR]，5.94[95%CI，4.29-8.24]）、遗传性易栓症（OR，2.64[95%CI，1.32-5.28]）、膝关节置换术（OR，1.65[95%CI，1.29-2.10]）和男性（OR，1.34[95%CI，1.08-1.67]）。在 7844 对 DOAC-阿司匹林配对患者的倾向评分匹配队列中，术后 30 天内 VTE 的风险无显著差异（OR，1.14[95%CI，0.82-1.59]），但接受 DOAC 治疗的患者术后出血更为常见（OR，1.36[95%CI，1.13-1.62]）。
在这项接受全髋关节或全膝关节置换术的患者队列研究中，潜在的患者危险因素，但不是阿司匹林或 DOAC 的选择，与术后 VTE 相关。接受阿司匹林治疗的患者术后出血率较低。这些结果表明，血栓预防策略应基于患者个体的血栓和出血风险，并进行个体化定制。
