![]() We recommend using aspirin, considering that it may be less effective than or as effective as LMWH for prevention of DVT and PE after THA, TKA, and hip-fracture surgeryĪspirin may be associated with less bleeding after THA, TKA, and hip-fracture surgery than other pharmacological agentsĪspirin may be less effective than or as effective as LMWHs for prevention of DVT and PE after other orthopedic procedures Hip fracture, hip arthroplasty, or knee arthroplasty If a DOAC is not used, the panel suggests using LMWH rather than warfarin and recommends LMWH rather than UFH The panel suggests using any of the DOACs approved for use When anticoagulants are used, the panel suggests using DOACs over LMWH The ASH guideline panel suggests using aspirin (ASA) or anticoagulants We suggest the use of pharmacologic agents and/or mechanical compressive devices for the prevention of VTE in patients undergoing elective hip or knee arthroplasty, and who are not at elevated risk beyond that of the surgery itself for VTE or bleeding In patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy and do not have a contraindication to aspirin, we suggest aspirin over no aspirin to prevent recurrent VTE Although aspirin may be better than placebo in regard to reducing VTE risk, there was still debate around the overall efficacy and safety of low-dose aspirin when compared with low-dose anticoagulants. However, the evidence of efficacy in the PEP study supported aspirin’s inclusion as an option to consider for postorthopedic surgical VTE prophylaxis, even in the early 2000s ( Table 1). ![]() There was also a trend toward more major nonfatal bleeding and nonfatal myocardial infarctions with aspirin, practically balancing out the benefit of VTE reduction. The statistical significance of benefit was seen primarily in the hip-fracture group, but not observed in the subgroup receiving low-molecular-weight heparin (LMWH) or in patients who were undergoing elective arthroplasty. 20 Other forms of thromboprophylaxis were concurrently allowed. Aspirin reduced the risk of symptomatic VTE by ∼36% when compared with placebo. In the PEP study, 17 000 patients undergoing surgery for hip fracture or elective arthroplasty were randomized to either 160 mg of aspirin daily or placebo, starting preoperatively and continued for 35 days. 19 This finding was reinforced by the multinational and prospective Pulmonary Embolism Prevention (PEP) study. In a meta-analysis of randomized studies by the Antiplatelet Trialists’ Collaboration in 1994, antiplatelet therapy (not exclusive to aspirin) was found to effect a significant reduction in VTE risk and a favorable trend toward mortality benefit (compared with no prophylaxis). ![]() We review the proposed mechanisms in which aspirin may act on venous thrombosis, the evidence for aspirin use in the primary and secondary prophylaxis of VTE, and the risk of bleeding with aspirin as compared with anticoagulation. Risk-benefit tradeoffs between aspirin and anticoagulants have changed, in part due to advances in surgical technique and postoperative care, and in part due to the development of safe, easy-to-use oral anticoagulants. Aspirin has long been an inexpensive cornerstone of arterial vascular disease therapy, but its role in the primary or secondary prophylaxis of VTE has been debated. Clinical research in the prevention and treatment of VTE has been a dynamic field of study, with investigations into various treatment modalities ranging from mechanical prophylaxis to the direct oral anticoagulants. Venous thromboembolism (VTE deep vein thrombosis and/or pulmonary embolism) is a well-established cause of morbidity and mortality in the medical and surgical patient populations.
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