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Association of Aspirin With Prevention of Venous Thromboembolism in Patients After Total Knee Arthroplasty Compared With Other Anticoagulants: A Noninferiority Analysis.
JAMA Surgery ( IF 15.7 ) Pub Date : 2019-01-01 , DOI: 10.1001/jamasurg.2018.3858
Brandon R Hood 1 , Mark E Cowen 2 , Huiyong T Zheng 1 , Richard E Hughes 1 , Bonita Singal 1 , Brian R Hallstrom 1
Affiliation  

Importance There has been significant debate in the surgical and medical communities regarding the appropriateness of using aspirin alone for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA). Objective To determine the acceptability of aspirin alone vs anticoagulant prophylaxis for reducing the risk of postoperative VTE in patients undergoing TKA. Design, Setting, and Participants Noninferiority study of a retrospective cohort of TKA cases submitted to the Michigan Arthroplasty Registry Collaborative Quality Initiative at 29 member hospitals, ranging from small community hospitals to large academic and nonacademic medical centers in Michigan. The study included 41 537 patients who underwent primary TKA between April 1, 2013, and October 31, 2015. Clinical events were monitored for 90 days after surgery. Data were analyzed between September and October 2016. Exposures The method of pharmacologic prophylaxis: neither aspirin nor anticoagulants for 668 patients (1.6%), aspirin only for 12 831 patients (30.9%), anticoagulant only (eg, low-molecular-weight heparin, warfarin, and Xa inhibitors) for 22 620 patients (54.5%), and both aspirin/anticoagulant for 5418 patients (13.0%). Most patients were also using intermittent pneumatic compression stockings. Main Outcome and Measures The primary composite outcome was the first occurrence of VTE or death. The noninferiority margin was specified as 0.3. The secondary outcome was bleeding events. Results Of the 41 537 patients, 14 966 were men (36%), and the mean age was 65.8 years. A VTE event occurred in 573 of 41 537 patients (1.38%); 32 of 668 (4.79%) who received no pharmacologic prophylaxis, 149 of 12 831 (1.16%) treated with aspirin alone, 321 of 22 620 (1.42%) with anticoagulation alone, and 71 of 5418 (1.31%) prescribed both aspirin and anticoagulation. Aspirin only was noninferior for the composite VTE outcome compared with those receiving other chemoprophylaxis (adjusted odds ratio, 0.85; 95% CI, 0.68-1.07, P for inferiority = .007). Bleeding occurred in 457 of 41 537 patients (1.10%), 10 of 668 (1.50%) without prophylaxis, 116 of 12 831 (0.90%) in the aspirin group, 258 of 22 620 (1.14%) with anticoagulation, and 73 of 5418 (1.35%) of those receiving both. Aspirin alone was also noninferior for bleeding complications (adjusted odds ratio, 0.80; 95% CI, 0.63-1.00, P for inferiority <.001). Conclusions and Relevance In this study of patients undergoing TKA, aspirin was not inferior to other anticoagulants in the postoperative rate of VTE or death. Aspirin alone may provide similar protection from postoperative VTE compared with other anticoagulation treatments.

中文翻译:

与其他抗凝药相比,全膝关节置换术后阿司匹林与预防静脉血栓栓塞的关联:非劣效性分析。

重要性在外科和医学界,关于在全膝关节置换术(TKA)后单独使用阿司匹林预防静脉血栓栓塞(VTE)的适当性存在重大争论。目的确定阿司匹林单独与抗凝剂预防在降低TKA患者术后VTE风险方面的可接受性。设计,背景和参与者非劣势性TKA病例回顾性队列研究提交给了密歇根州人工关节置换注册质量合作计划的29家成员医院,从小型社区医院到密歇根州的大型学术和非学术医疗中心。该研究包括41 537例在2013年4月1日至2015年10月31日之间接受原发性TKA的患者。在术后90天对临床事件进行监测。分析了2016年9月至2016年10月之间的数据。暴露药理预防方法:668例患者(1.6%)既不使用阿司匹林也不使用抗凝剂,仅12 831例患者中既不使用阿司匹林(30.9%),仅使用抗凝剂(例如,低分子量肝素) ,华法林和Xa抑制剂)治疗22 620例患者(占54.5%),阿司匹林/抗凝药均治疗5418例患者(占13.0%)。大多数患者还使用间歇性气压袜。主要结果和措施主要的综合结果是首次发生VTE或死亡。非劣质性余量指定为0.3。次要结果是出血事件。结果在41 537例患者中,男性14 966例(36%),平均年龄为65.8岁。41 537例患者中有573例发生了VTE事件(1.38%);668名患者中有32名(4.79%)没有接受药物预防,单独使用阿司匹林治疗的患者有12 831名,其中149名(1.16%),仅接受抗凝治疗的有22 620名(1.22%),有5418分中的71项(1.31%)均接受了阿司匹林和抗凝治疗。与接受其他化学预防措施的患者相比,仅阿司匹林的综合VTE结果不逊色(校正后的优势比为0.85; 95%CI为0.68-1.07,自卑者P = .007)。41 537例患者中的457例(1.10%),668例中有10例(1.50%)未出血,阿司匹林组中的116例12 831(0.90%)中,22 620例中的258例(1.14%)有抗凝作用,73例中有73例发生出血。接受这两项的人数中,有5418人(1.35%)。单独使用阿司匹林在出血并发症方面也不逊色(校正后的优势比为0.80; 95%CI为0.63-1.00,自卑<0.001)。结论与相关性在这项针对TKA患者的研究中,阿司匹林在术后VTE或死亡率方面不逊于其他抗凝剂。与其他抗凝治疗相比,单独使用阿司匹林可能对术后VTE提供类似的保护。
更新日期:2019-01-17
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