Aspirin for Venous Thromboembolic Prophylaxis Following Total Hip and Total Knee Arthroplasty: An Analysis of Safety and Efficacy Accounting for Surgeon Selection Bias

Tranexamic Acid Is Safe in Arthroplasty Patients Who Have a History of Venous Thromboembolism: An Analysis Accounting for Surgeon Selection Bias

BACKGROUND

Retrospective data supporting the use of tranexamic acid (TXA) among high-risk total joint arthroplasty (TJA) patients are limited by surgeon selection bias. This study sought to evaluate the thromboembolic risk associated with TXA administration among elective arthroplasty patients who have history of venous thromboembolism while accounting for surgeon selection.

METHODS

A healthcare database was retrospectively queried from 2015 to 2021 to identify all patients who had a history of deep vein thrombosis or pulmonary embolism who underwent elective TJA. Patients were categorized into two cohorts: (1) patients treated by a surgeon who used TXA in 0 to 30% of cases; and (2) patients treated by a surgeon who used TXA in 90 to 100% of cases. Patients were assessed based on the surgeon who treated them rather than their exposure to TXA. Demographics, comorbidities, and the incidence of 90-day postoperative complications were compared between the two groups. Multivariable and instrumental variable analysis using surgeon as an instrument were conducted to account for confounding factors.

RESULTS

In total, 70,759 high-risk elective TJA patients were identified, of which 7,190 (10.2%) were performed by surgeons in the infrequent-TXA cohort and 9,478 (13.4%) were performed by surgeons in the frequent-TXA cohort. On instrumental variable analysis, patients treated by surgeons in the frequent-TXA cohort had a lower risk of aggregate bleeding complications (instrumental variable odds ratio 0.94, 95% confidence interval: 0.89 to 0.98, P = 0.005), including transfusion (instrumental variable odds ratio 0.60, 95% confidence interval: 0.54 to 0.66, P < 0.001). However, no significant differences were observed in postoperative deep vein thrombosis, pulmonary embolism, stroke, and myocardial infarction between the two cohorts (P > 0.05).

CONCLUSIONS

After accounting for surgeon selection, TXA administration was associated with a significant reduction in early postoperative bleeding complications with no observed increase in thromboembolic risk. Given the favorable safety profile, surgeons should consider TXA among high-risk arthroplasty patients.

Rivaroxaban Utilization without Perioperative Tranexamic Acid is Associated with an Increased Risk of Bleeding Complications Following Total Joint Arthroplasty

INTRODUCTION

Rivaroxaban provides effective venous thromboembolic (VTE) prophylaxis, but there are concerns about associated bleeding in total joint arthroplasty (TJA) patients. This study aimed to investigate whether the perioperative administration of tranexamic acid (TXA) in TJA patients receiving rivaroxaban for thromboprophylaxis is associated with a reduced risk of postoperative bleeding complications.

METHODS

The healthcare database was utilized to identify all primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients between 2015 and 2021. Patients receiving rivaroxaban during their in-hospital admission who also received TXA on the day of surgery were compared to those who did not receive TXA. Univariate and multivariable regression analyses assessed differences in 90-day bleeding, thromboembolic, and medical postoperative outcomes between cohorts. In total, 161,585 TJA patients were identified (TKA: 67.3%; THA: 32.7%), of which 41,899 (25.9%) received rivaroxaban alone, and 119,686 (74.1%) received rivaroxaban plus TXA.

RESULTS

Multivariable analyses found that patients who received rivaroxaban and TXA had a reduced risk of aggregate bleeding complications (adjusted odds ratio [aOR] 0.7, 95% confidence interval [CI]: 0.7 to 0.7, P < 0.001), transfusion (aOR 0.4, 95% CI: 0.4 to 0.4, P < 0.001), acute anemia (aOR 0.7, 95% CI: 0.7 to 0.8, P < 0.001), deep vein thrombosis (aOR 0.8, 95% CI: 0.7 to 0.9, P < 0.001), and pulmonary embolism (aOR 0.8, 95% CI: 0.7 to 0.9, P = 0.012). No differences between cohorts were observed for the risk of stroke (aOR 0.9, 95% CI: 0.7 to 1.1, P = 0.307) and myocardial infarction (aOR 0.9, 95% CI: 0.7 to 1.1, P = 0.305). Procedure-specific subanalysis demonstrated a reduced risk of aggregate bleeding complications, transfusion, and acute anemia following THA and TKA.

CONCLUSION

Perioperative administration of TXA reduced the risk of bleeding complications without increasing thromboembolic risk among patients receiving rivaroxaban. Arthroplasty surgeons should consider administering TXA to primary THA and TKA patients receiving rivaroxaban.

Sexual Dimorphism in Cardiometabolic Diseases: From Development to Senescence and Therapeutic Approaches

The global incidence and prevalence of cardiometabolic disorders have risen significantly in recent years. Although lifestyle choices in adulthood play a crucial role in the development of these conditions, it is well established that events occurring early in life can have an important effect. Recent research on cardiometabolic diseases has highlighted the influence of sexual dimorphism on risk factors, underlying mechanisms, and response to therapies. In this narrative review, we summarize the current understanding of sexual dimorphism in cardiovascular and metabolic diseases in the general population and within the framework of the Developmental Origins of Health and Disease (DOHaD) concept. We explore key risk factors and mechanisms, including the influence of genetic and epigenetic factors, placental and embryonic development, maternal nutrition, sex hormones, energy metabolism, microbiota, oxidative stress, cell death, inflammation, endothelial dysfunction, circadian rhythm, and lifestyle factors. Finally, we discuss some of the main therapeutic approaches, responses to which may be influenced by sexual dimorphism, such as antihypertensive and cardiovascular treatments, oxidative stress management, nutrition, cell therapies, and hormone replacement therapy.

[Modern Approach to the Use of Aspirin in Prevention of Venous Thromboembolism Following Total Hip Arthroplasty or Total Knee Arthroplasty. A Retrospective Trial]

PURPOSE OF THE STUDY

Given the risk of venous thromboembolism (DVT) and pulmonary embolism (PE) after large joint replacement, the role of thromboprophylaxis is crucial. This retrospective study aims to evaluate the effectiveness of aspirin as thromboprophylaxis in patients undergoing TKA or THA.

MATERIAL AND METHODS

In this retrospective review of a database of patients who underwent total hip and total knee replacements between 2021 and 2023, we divided patients into two groups: those with no anticoagulation therapy before surgery and those on chronic anticoagulant use prior to surgery. The primary endpoint was the number of patients with complications after aspirin use in the postoperative period. We collected patient demographic information, history of anticoagulant use, postoperative anticoagulant usage, comorbidities, type of surgery, reactions to anticoagulants, complications related to thromboembolism, length of hospital stay, and hospital readmissions.

RESULTS

For patients who underwent elective THA or TKA, no significant difference in overall VTE or PE rates was detected when comparing aspirin with other anticoagulants. No mortality events were reported. However, there were differences in bleeding event rates between the aspirin group and other anticoagulant groups.

CONCLUSIONS

Proper patient selection and early postoperative mobilization support the use of aspirin as a thromboprophylaxis therapy. The results of this study confirm that aspirin is a safe alternative to other anticoagulants in the postoperative management of THA and TKA.

Low-versus high-dose aspirin for venous thromboembolic prophylaxis after total joint arthroplasty: a systematic review and meta-analysis

BACKGROUND

The adverse effects of aspirin are dose-dependent, and there is controversy surrounding the use of low-dose (LD) aspirin to prevent venous thromboembolism (VTE) following total joint arthroplasty (TJA). This meta-analysis sought to compare the efficacy and complication rate of low-dose (162 mg per day) versus high-dose (HD, 650 mg per day) aspirin after TJA surgery.

METHODS

In four main databases, we searched from inception until September 2024 for articles comparing the rate of VTE following TJA(TKA/THA) using only aspirin chemoprophylaxis with different dosages. We meta-analyzed and compared the VTE and complication rates of LD aspirin (162 mg per day) with HD aspirin (650 mg per day) and presented our results as odds ratio (ORs) in forest plot diagrams.

RESULTS

There were 14 eligible studies, comprising 43,518 patients in the LD group and 62,645 patients in the HD group. DVT (OR: 1.37, CI: 0.93-2.02, P = 0.11) and PE (OR: 1.86, CI: 0.73-4.72, P = 0.19) rates were similar between the groups. However, taking VTE as the total number of cases with DVT or PE, the incidence was significantly higher in the HD group than in the LD group (OR:1.53, CI: 1.17-2.00, P = 0.002). HD also had a significantly higher rate of PJI (OR:2.68 CI:1.5-4.6 P = 0.001), but gastrointestinal bleeding (GIB) was similar between the two groups (OR: 0.97, CI: 0.42-2.22, P = 0.95).

CONCLUSION

The findings suggest that LD aspirin may be a viable option for VTE chemoprophylaxis following TJA, potentially offering comparable efficacy with a lower risk of PJI compared to HD aspirin regimens.

LEVEL OF EVIDENCE

Therapeutic Level II.

The Use of Aspirin for Venous Thromboembolism Prophylaxis in Patients Who Have Morbid Obesity Undergoing Primary and Revision Total Joint Arthroplasty

BACKGROUND

Venous thromboembolism (VTE) poses a major clinical concern due to its life-threatening nature, and obese and morbidly obese patients are thought to be at an increased risk for VTE. The aims of this study were twofold; first, to explore VTE rates in patients who have a body mass index (BMI) > 40 undergoing primary and revision total joint arthroplasty, and second, to investigate aspirin (ASA) efficacy and safety.

METHODS

We identified all patients (n = 4,672) who had a BMI > 40 who underwent primary and revision total joint arthroplasty from 2016 to 2022 at a single academic tertiary care center. Patients were stratified by BMI groups: 40 to 44.9 (n = 3,462), 45 to 49.9 (n = 935), and 50+ (n = 275). The primary outcome was any VTE event within 90 days postoperatively. The secondary outcome consisted of wound complications within 90 days postoperatively.

RESULTS

The total VTE rate was 0.4% (n = 21) and did not differ statistically between the BMI groups (0.4 versus 0.4 versus 0.7%, P = .669). The VTEs consisted of 6 deep venous thromboses (DVTs), 14 pulmonary embolisms, and one concomitant deep venous thrombosis and pulmonary embolism. The VTE rates were not statistically different between patients who received aspirin 325 mg 0.5% (n = 9), aspirin 81 mg 0.2% (n = 1), aspirin + anticoagulant (AC) 0.5% (n = 6), and AC alone 0.4% (n = 5) (P = .954). In addition, wound complications did not differ significantly between patients who received ASA 325 mg, ASA 81mg, ASA + AC, or AC alone (1.6 versus 1.0 versus 1.8 versus 1.1%, P = .351).

CONCLUSIONS

The use of aspirin 325 and 81 mg was found to have similar VTE rates as aspirin + ACs and ACs alone, with no significant increase in wound complications. In patients who have a BMI > 40, the use of aspirin is a safe option for VTE prophylaxis and should be prescribed in the context of the patient who has other risk factors for VTE.

Trends in deep vein thrombosis prophylaxis after total hip arthroplasty: 2016 to 2021

Introduction

Venous thromboembolism (VTE) has long been acknowledged as a potential complication of total hip arthroplasty (THA) contributing to heightened patient morbidity, mortality, and substantial healthcare costs. We aimed to: 1) assess trends in VTE prophylaxis utilization between 2016 and 2021; 2) determine the incidence of postoperative VTE and transfusions; and 3) identify independent risk factors for 90-day VTE and transfusion risks following THA in relation to the use of aspirin, dabigatran, enoxaparin, rivaroxaban, and warfarin.

Methods

A national, all-payer database was queried from January 1, 2016 and December 31, 2022. Use trends for aspirin, enoxaparin, rivaroxaban, dabigatran, and warfarin as thromboprophylaxis following THA was assessed. Incidence of ninety-day postoperative outcomes assessed included rates of 90-day postoperative VTE and transfusion.

Results

From 2016 to 2021, aspirin (n = 36,346) was the most used agent for VTE prophylaxis after THA, followed by dabigatran (n = 13,065), rivaroxaban (n = 11,790), enoxaparin (n = 11,380), and warfarin (n = 6326). Independent risk factors for 90-day VTE included CKD, COPD, CHF, obesity, dabigatran, enoxaparin, rivaroxaban, and warfarin (all p < 0.05).

Conclusion

Aspirin was used with increasing frequency and demonstrated lower rates of VTE and transfusion following THA, compared to dabigatran, enoxaparin, rivaroxaban, and warfarin. These findings seem to indicate that the increasing use of aspirin in VTE prophylaxis has been accomplished in appropriately selected patients.