Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty

Johanson, Norman A.; Lachiewicz, Paul F.; Lieberman, Jay R.; Lotke, Paul A.; Parvızı, Javad; Pellegrini, Vincent D.; Stringer, Theodore A.; Tornetta, Paul; Haralson, Robert H.; Watters, William C.

doi:10.5435/00124635-200903000-00007

Cited by 190 publications

(159 citation statements)

References 37 publications

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“…The American Academy of Orthopaedic Surgeons (AAOS) has endorsed aspirin for VTE prevention after TJA [23]. In 2012, the American College of Chest Physician (ACCP) evidence-based clinical practice guidelines (9 th edition), for the first time, acknowledged the use of aspirin as a means of PE chemoprophylaxis after TJA (Grade IB recommendation) [13,18].…”

Section: Introductionmentioning

confidence: 99%

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

Raphael

Tischler

Huang

et al. 2013

Clin Orthop Relat Res

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Background The most effective agent for prophylaxis against venous thromboembolic disease after total joint arthroplasty (TJA) remains unknown. The paucity of literature comparing different methods of pulmonary embolism (PE) prophylaxis and fear of litigation make it difficult for surgeons to abandon the use of aggressive chemical prophylaxis. Questions/purposes We compared the (1) overall frequency of symptomatic PE, (2) risk of symptomatic PE after propensity matching that adjusted for potentially confounding variables, and (3) other complications and length of stay before and after propensity matching in patients undergoing TJA at our institution who received either aspirin or warfarin prophylaxis. Methods A total of 28,923 patients underwent TJA between

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Section: Introductionmentioning

confidence: 99%

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

Raphael

Tischler

Huang

et al. 2013

Clin Orthop Relat Res

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“…Interestingly, potent anticoagulants such as warfarin and LMWH are associated with increased all-cause mortality rates, including PE, when compared to pneumatic compression boots and aspirin [20]. It is from this point of view that the AAOS created the guidelines stating patients at a standard risk of both PE and bleeding can be given aspirin, LMWH, synthetic pentasaccharides, or warfarin to reach an INR goal of 2 or lower [11]. A previous prospective study from this institution that involved performing preoperative and postoperative VQ scans in a consecutive series of patients undergoing TJA found low-dose warfarin (with an INR goal\2) is effective at minimizing development of PE, with a low (2.4%) bleeding complication [1].…”

Section: Discussionmentioning

confidence: 99%

“…Patients continued on the anticoagulation for a period of 6 weeks. The institutional guidelines are modeled after the recommendations from the American Academy of Orthopaedic Surgeons (AAOS) [11] for prevention of PE after TJA. These guidelines were developed without regard for the prevention of DVT.…”

Section: Patients and Materialsmentioning

confidence: 99%

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Does International Normalized Ratio Level Predict Pulmonary Embolism?

Hansen

Zmistowski

Restrepo

et al. 2012

Clinical Orthopaedics &Amp; Related Research

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Background Preventing pulmonary embolism is a priority after major musculoskeletal surgery. The literature contains discrepant data regarding the influence of anticoagulation on the incidence of pulmonary embolism after joint arthroplasty. The American College of Chest Physicians guidelines recommend administration of oral anticoagulants (warfarin), aiming for an international normalized ratio (INR) level between 2 and 3. However, recent studies show aggressive anticoagulation (INR [ 2) can lead to hematoma formation and increased risk of subsequent infection. Questions/purposes We asked whether an INR greater than 2 protects against pulmonary embolism. Patients and Methods We identified 9112 patients with 10,122 admissions for joint arthroplasty between 2004 and 2008. All patients received warfarin for prophylaxis, aiming for an INR level of 2 or lower. We assessed 609 of 10,122 admissions (6%) for pulmonary embolism using CT, ventilation/perfusion scan, or pulmonary angiography, and 163 of 10,122 admissions (1.6%) had a proven pulmonary embolism. Results Fifteen of 163 admissions (9%) had an INR greater than 2 before or on the day of workup compared to 35 of 446 admissions (8%) who were negative. We observed no difference between the INR values in patients with or without pulmonary embolism. Conclusions We found no clinically relevant difference in the INR values of patients who did or did not develop pulmonary embolism. The risk of bleeding should be weighed against the risk of pulmonary embolism when determining an appropriate target INR for each patient, as an INR less than 2 may reduce the risk of bleeding while still protecting against pulmonary embolism. Level of Evidence Level III, therapeutic study. See Instructions to Authors for a complete description of levels of evidence.

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“…The recommended target INR window is between 1.5 and 2.0. 9,10 Moreover, warfarin genetic testing is not routinely recommended. However, efficient anticoagulation to the desired levels is critical due to the high rate of venous thrombosis in these patients.…”

Section: Introductionmentioning

confidence: 99%