Rivaroxaban versus aspirin in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery: a meta-analysis

Hu, Bangsheng; Jiang, Lianxiang; Tang, Hong; Hu, Meizhu; Yu, Jie; Zhang, Dai

doi:10.1186/s13018-021-02274-z

Cited by 10 publications

(4 citation statements)

References 22 publications

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“…Given that our control group contained two anticoagulants, warfarin and rivaroxaban, analyzed separately according to the type of anticoagulant, it was found that aspirin and rivaroxaban showed similar effects in preventing venous thrombosis. This is consistent with the results of a large cohort observational study ( Bala et al, 2017 ) and previous meta-analyses ( Kapoor et al, 2017 ; Matharu et al, 2020 ; Hu et al, 2021 ). However, in comparison to warfarin, aspirin demonstrated a lower efficacy in preventing VTE.…”

Section: Discussionsupporting

confidence: 92%

“…VTE is the most common cause of perioperative hospital deaths, and its complications consume a significant amount of healthcare resources ( Reddy et al, 2022 ). Anticoagulants have been shown to reduce postoperative mortality and VTE-related complications ( Hu et al, 2021 ). Aspirin has the advantage of being widely available, inexpensive, does not require monitoring, and is traditionally considered to have a lower bleeding risk than anticoagulants in the perioperative period ( Diep and Garcia, 2020 ).…”

Section: Discussionmentioning

confidence: 99%

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Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

Zheng,

Nong,

Song

et al. 2024

Front. Pharmacol.

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Background: venous thromboembolism (VTE) is one of the most common complications after major orthopaedic surgery. Recent studies have suggested that aspirin may also be effective in preventing VTE, but it is still controversial whether it can be routinely used.Objectives: To compare the efficacy and safety of aspirin against oral anticoagulants in the prevention of VTE following total hip arthroplasty (THA), total knee arthroplasty (TKA) or hip fracture surgery (HFS).Methods: Relevant publications have been obtained using electronic search databases such as PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials. gov. from inception to 20 July 2023. Only RCTs evaluating the efficacy and safety of aspirin compared with oral anticoagulants undergoing major orthopaedic surgery were included in the meta-analysis. The primary outcome reported was any VTE event (including deep vein thrombosis (DVT) and pulmonary embolism (PE)). Secondary outcomes included mortality, major bleeding (including gastrointestinal bleed, cerebrovascular hemorrhage, or any bleeding requiring a return to the theater), minor bleeding (ecchymosis, epistaxis, hematuria), and wound complications. The risk of bias for all included studies was assessed according to the Cochrane Collaboration’s tool.Results: After screening 974 studies, 12 randomized clinical trials (RCTs) were included, involving 5,088 participants, including 2,540 participants in aspirin, 2,205 participants in rivaroxaban, and 323 participants in warfarin. Aspirin was found to be less effective than oral anticoagulants in thromboprophylaxis after major orthopedic surgery (RR = 1.206, 95% CI 1.053–1.383). After subgroup analysis according to the type of oral anticoagulant, the results showed that aspirin was similar to rivaroxaban and inferior to warfarin. Considering that the studies in the warfarin group were all conducted before 2000, our results need to be further confirmed. In addition, the aspirin group had a higher risk of VTE than the control group in other subgroups, including a follow-up time of ≤3 months, type of procedure as TKA, high-dose aspirin (≥650 mg qd), and no combined use of mechanical prophylaxis. In terms of safety events, aspirin did not show significant differences in major bleeding (RR = 0.952, 95% CI 0.499–1.815), all-cause mortality (RR = 1.208, 95% CI 0.459–3.177), and wound-related events (RR = 0.618, 95% CI 0.333–1.145) compared with oral anticoagulants, and aspirin was associated with a reduction in the risk of minor bleeding (RR = 0.685, 95% CI 0.552–0.850) events and total bleeding (RR = 0.726, 95% CI 0.590–0.892).Conclusion: Aspirin reduces bleeding risk after major orthopedic surgery compared with oral anticoagulants, but may sacrifice VTE prevention to some extent. Updated evidence is needed to analyze the thromboprophylaxis effects of aspirin in patients undergoing major orthopedic surgery.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463481, identifier CRD42023463481.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

Zheng,

Nong,

Song

et al. 2024

Front. Pharmacol.

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“…Regarding secondary outcomes, our mortality, bleeding events, and wound complication results were similar to those reported by previous studies, which found no significant differences between aspirin and other anticoagulants ( 10 , 11 , 15 , 18 , 29 , 30 ). Furthermore, Yhim et al , in a population-based epidemiological study of 306 912 cases (261 260 TKA and 45 652 THA), found that patients who had aspirin as an thromboprophylactic agent had no increased risk for blood transfusion when compared with other anticoagulants (LMWH odds ratio, OR = 1.6 (1.56–1.65), rivaroxaban OR = 1.46 (1.42–1.50), and fondaparinux OR = 1.25 (1.18–1.33)) ( 29 ).…”

Section: Discussionsupporting

confidence: 90%

Clinical effectiveness and safety of aspirin and other anticoagulants for venous thromboembolism prophylaxis after major orthopedic surgery: a systematic review and meta-analysis of randomized clinical trials

et al. 2022

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Purpose Patients undergoing major orthopedic surgeries, such as total hip replacement (THR), total knee replacement (TKR), and trauma surgery, are at an elevated risk of venous thromboembolism (VTE), causing significant morbidity and mortality. Previous studies have investigated aspirin as a thromboprophylactic agent for arthroplasty, besides trauma surgery. Therefore, we sought to analyze the efficacy of aspirin compared to that of other anticoagulants for VTE prophylaxis in patients undergoing major orthopedic surgeries. Methods This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study protocol was registered with the PROSPERO register. Randomized controlled trials that investigated the use of aspirin for thromboprophylaxis in major orthopedic lower limb surgeries were included and analyzed. Quality analysis of the literature and level of evidence were assessed. The primary clinical outcome was VTE. Secondary clinical outcomes included mortality, bleeding events, and wound complications. Results Eight high-quality studies with level 2 evidence (published within 2006–2021) were included, comprising 6220 patients. The incidence of VTE with aspirin was not found to be more significant than other anticoagulants (risk ratio (RR) = 1.18, 95% CI: 0.89–1.58, P = 0.25). Regarding secondary outcomes, there were no significant differences between aspirin and other anticoagulants (mortality (RR = 1.40, 95% CI: 0.27–7.23, P = 0.69), bleeding events (RR = 0.89, 95% CI: 0.57–1.39, P = 0.61), or wound complications (RR = 0.64, 95% CI: 0.30–1.35, P = 0.24)). Conclusion The current meta-analysis did not show any difference between aspirin and other anticoagulants as thromboprophylactic agents in preventing VTE in patients who underwent major orthopedic surgeries.

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“…ASA and DOAC use have come under investigation of late. Two heterogenous meta-analyses, recently published, suggest favorable findings with regards to VTE reduction, however level one evidence is yet to emerge 268,269 . Both agents are convenient given their more simplistic oral regimens and encouragingly low rates of VTE, but reservations persist concerning hemorrhagic events, particularly in the immediate postoperative period 263,270 .…”

Section: - What Is the Most Optimal Vte Prophylaxis For Patients Unde...mentioning

confidence: 99%

Recommendations from the ICM-VTE: Trauma

2022

Journal of Bone and Joint Surgery

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The ICM-VTE Trauma Delegates* 1 -What is the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries?Response/Recommendation: Although multiple forms of prophylaxis against venous thromboembolism (VTE) with variable effectiveness are available for patients with multiple orthopedic injuries, low-molecular-weight heparin (LMWH) is considered the most optimal choice based on available literature.Strength of Recommendation: Acceptable.Delegates vote: Agree 86.36% Disagree 9.09% Abstain 4.55% (Strong Consensus).Rationale: VTE events following multiple orthopaedic injuries are associated with significant morbidity and mortality 1,2 . The prevalence of deep venous thrombosis (DVT) in trauma patients without prophylactic treatment can reach up to 60%. Pulmonary embolism (PE) can be a fatal form of VTE with prevalence ranging between 2 -16% 3,4 . VTE can be prevented using different mechanical and chemical prophylaxis agents, therefore, significantly lower the burden on healthcare systems worldwide 1 . The aim of this review is to find the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries.Multiple orthopaedic injuries rarely happen without extraskeletal injuries, therefore, no studies in the current literature addressed VTE prophylaxis in patients with multiple orthopaedic injuries but without extra-skeletal injuries. Most of the available literature is addressing this patient population under different groups including, patients with trauma, poly-trauma, high energy fractures and lower extremity injuries [1][2][3][5][6][7] . The level of evidence varies among the reviewed literature, however, randomized controlled clinical trials in this subject are limited 3,4 .Based on our review, LMWH is considered the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries 1,3,5,6,[8][9][10][11][12][13][14] . Ley et al., recommends using LMWH due to its increased bioavailability, acceptably low bleeding complications and longer plasma half-life 1 . Rogers et al., published in their guidelines for prevention of VTE in trauma patients that LMWH has superior bioavailability when compared to lowdose heparin (LDH) 5 . Knudson et al., concluded in a prospective, randomized trial that LMWH is an extremely effective *A list of the ICM-VTE Trauma Delegates is included in a note at the end of the article. Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G855).

show abstract

Rivaroxaban versus aspirin in prevention of venous thromboembolism following total joint arthroplasty or hip fracture surgery: a meta-analysis

Cited by 10 publications

References 22 publications

Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

Clinical effectiveness and safety of aspirin and other anticoagulants for venous thromboembolism prophylaxis after major orthopedic surgery: a systematic review and meta-analysis of randomized clinical trials

Recommendations from the ICM-VTE: Trauma

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