The risk of venous thromboembolism with aspirin compared to anticoagulants after hip and knee arthroplasty

Abstract

Background Recent guidelines include aspirin as an option to prevent venous thromboembolism (VTE) in selected patients undergoing hip or knee replacement surgery. However, the efficacy of aspirin after arthroplasty has not been well-defined, particularly in more contemporary patient populations. We compared rates of post-operative VTE between patients who received aspirin-only versus anticoagulants after hip or knee arthroplasty, using data from a large US-based administrative database. Materials and Methods We conducted a retrospective cohort study of 231,780 adults who underwent total knee arthroplasty and 110,621 who underwent total hip arthroplasty in 2009–2012 and who received pharmacologic VTE prophylaxis (aspirin or anticoagulant) within the first 7 days after surgery. We compared the risk of post-operative VTE between patients receiving aspirin-only vs. anticoagulants, controlling for clinical and hospital characteristics using multivariable logistic regression with propensity score adjustment. Results Aspirin-only prophylaxis was administered to 7.5% of patients after knee arthroplasty and 8.0% after hip arthroplasty. Post-operative VTE was diagnosed in 2,217 (0.96%) patients after knee arthroplasty and 454 (0.41%) after hip arthroplasty. Compared to anticoagulants, aspirin was not associated with a higher risk for post-operative VTE either after knee arthroplasty (adjusted odds ratio and 95% confidence interval [OR] 0.34 [0.24–0.48]) or hip arthroplasty (OR 0.82 [0.45–1.51]). Conclusions Aspirin was uncommonly administered as the sole prophylactic agent after hip or knee arthroplasty in this study. However, patients who received aspirin-only had similar rates of post-operative VTE compared to patients who received anticoagulants. Further research should focus on distinguishing which patients benefit more from anticoagulants versus aspirin after arthroplasty.

Aspirin Compared with Anticoagulation to Prevent Venous Thromboembolism After Knee or Hip Arthroplasty: a Large Retrospective Cohort Study

“…Compared with previous findings, the frequency of using aspirin-only for postoperativethromboprophylaxis in patients undergoing knee or hip arthroplasty was higher in our study. 6,17 Our previous retrospective cohort study which similarly investigated thromboembolic risk in a large nationally representative sample of patients receiving aspirin compared with anticoagulation after knee or hip replacement surgery between 2009 and 2012 in the USA found that aspirin-only was administered in 7.5-8% of cases, 6 while this proportion increased to more than 27% in our current study that covered a timeframe after publication of the updated American College of Chest Physicians (ACCP) guidelines. Similarly, a recent retrospective chart review of 329 patients undergoing knee arthroplasty at 2 tertiary care centers found that the proportion of patients receiving monotherapy with aspirin for postoperative thromboprophylaxis increased from 4.6 to 44.4% in the periods before and after the publication of ACCP guidelines in 2012 18 ; in these updated guidelines, the use of aspirin as a sole thromboprophylactic agent after knee or hip arthroplasty was newly endorsed and hence, consensus was reached with the recommendations made by the American Academy of Orthopedic Surgeons (AAOS).…”

“…10 Venous thromboembolism diagnoses included lower extremity deep vein thrombosis and pulmonary embolism events and were based on ICD-9 codes (online Supplemental Table 1). 6,9,11 Follow-up for thromboembolic events started at the day of surgery. Events that occurred after discharge and led to readmission within 30 days were based on primary diagnosis codes for venous thromboembolism, and we also considered outpatient encounters for venous thromboembolism within 90 days after discharge.…”

“…However, evidence on the comparative efficacy of aspirin for venous thromboembolism prevention after joint arthroplasty in contemporary populations is limited and of low quality. 4,5 Previous studies found low rates of aspirin use for venous thromboembolism prevention in patients with knee or hip arthroplasty, 6 but the adoption of these new guideline recommendations might have led to changes in the use of aspirin for perioperative thromboprophylaxis in more recent cohorts, especially in light of a movement towards non-pharmacologic interventions that likely additionally reduce the rates of venous thromboembolism diagnoses, such as early mobility and recommendations against Doppler ultrasonography screening. 1 Therefore, our aim was to describe management strategies for pharmacologic thromboprophylaxis in a large contemporary cohort of patients undergoing knee or hip arthroplasty and to assess and compare the risk of postoperative venous thromboembolism in patients receiving aspirin and those receiving anticoagulation for thromboprophylaxis.…”

Profilaxia do tromboembolismo venoso nas cirurgias do tornozelo e do pé

“…Although the literature is controversial on recommending ASA as a single agent for thromboprophylaxis, recent studies 44 demonstrate that it can be used after a short five-day cycle of a directacting oral anticoagulant (rivaroxaban) in hip and knee arthroplasties. 45,46 Studies on ASA as a thromboprophylaxis agent in ankle and foot surgeries are still scarce, as noted in a recent consensus on the subject. 17 Unfractionated heparin and LMWH inhibit several coagulation proteases (►Figure 2).…”

Capsule Commentary on Baumgartner et al., Aspirin Compared with Anticoagulation to Prevent Venous Thromboembolism after Knee or Hip Arthroplasty: a Large Retrospective Cohort Study

“…For clinicians who care for joint arthroplasty patients postoperatively, this study adds to the growing literature supporting the use of aspirin as an acceptable option in preventing post-operative VTE. [3][4][5] As acknowledged by the authors, an ongoing randomized, head-to-head comparison of aspirin vs. other agents will likely better answer this question (PEPPER trial). Moreover, this work further establishes the need to develop a risk assessment tool and best practice recommendation that incorporates individual thrombosis risk (e.g., malignancy, h/o prior VTE) balanced by bleed risk to prospectively select appropriate candidates for aspirin prophylaxis in patients following arthroplasty.…”