Aspirin effective for VTE prevention in orthopedic surgery

Anna GarrettThere are many opinions about which anticoagulant is best to use after orthopedic surgery. National guidelines recommend the use of pharmacologic thromboprophylaxis to prevent venous thromboembolism (VTE) in these patients but fail to identify which agents are best, leaving individual physicians to determine the optimal therapy.

A recent review of eight trials involving about 1,400 patients compared rates of VTE and bleeding in the use of aspirin, heparin, and warfarin after major lower-extremity surgeries.

According to the findings, aspirin was just as effective as heparin and warfarin in preventing blood clots and caused 68% fewer serious bleeding events following hip or knee replacements. However, the study notes, administration of conventional anticoagulants is best after hip-fracture repair.

Source: Drescher FS, Sirovich BE, Lee A. et al. Aspirin vs. anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: A systematic review and meta-analysis. J Hosp Med 2014. Published online July 17, 2104. DOI: 10.1002/jhm.2224.

Thrombolytic therapy beneficial in treatment of PE

Thrombolytic therapy may be helpful in the treatment of some patients with pulmonary embolism; however, there has never been an analysis with adequate statistical power to determine whether it is associated with improved survival compared with standard anticoagulation.

Researchers performed a meta-analysis of eight trials involving 1,775 patients to determine mortality benefits and bleeding risks associated with thrombolytic therapy in acute pulmonary embolism.

Eligible studies were randomized clinical trials comparing thrombolytic therapy and anticoagulant therapy in pulmonary embolism patients. The primary outcomes were all-cause mortality and major bleeding. Secondary outcomes were risk of recurrent embolism and intracranial hemorrhage (ICH).

Use of thrombolytics was associated with lower all-cause mortality (2.17% vs. 3.89% with anticoagulants) and greater risks of major bleeding (9.24% vs. 3.42%) and ICH (1.46% vs. 0.19%). Major bleeding was not significantly increased in patients 65 years of age and younger. Thrombolysis was associated with a lower risk of recurrent pulmonary embolism. Similar results were found in intermediate-risk pulmonary embolism (hemodynamically stable with right ventricular dysfunction).

Source: Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: A meta-analysis. JAMA 2014;311(23):2414–21.

Guidelines published for management of anticoagulant-associated ICH

The Journal of Neurosurgery recently published a supplement to its August issue, titled "Race against the Clock: Overcoming Challenges in the Management of Anticoagulant-Associated Intracerebral Hemorrhage [AAICH]."

Intracranial hemorrhage is a medical emergency and more than one-third of patients who experience this do not survive. Of those who do, only 20% will regain functional independence. Management of ICH poses a greater challenge when it occurs in patients who receive anticoagulation therapy, because they are likely to have larger hemorrhages. As the population ages, the number of elderly patients who are on anticoagulants and have greater risk of bleeding continues to rise. Consequently, the number of cases of AAICH is on the rise. The mortality rate for this elderly subgroup may be as high as 42.3% to 67%.

The authors review use of current oral anticoagulation therapies and describe various agents' mechanisms of action. They also include data on the administration of vitamin K, fresh frozen plasma, prothrombin complex concentrates (both three-factor [used off-label] and four-factor PCCs), and recombinant factor VIIa, as well as the use of dialysis, in reversing the effects of anticoagulants. The authors also describe current and potential treatments used in cases of AAICH involving newer anticoagulants for which there exist no standard reversal protocols or reversal agents.

The guidelines discuss institutional protocols involving a multidisciplinary approach for the treatment of spontaneous ICH and AAICH and strongly recommend their development in individual institutions.

The supplement is free and available for online review and download at http://thejns.org/toc/sup/121/Suppl - http://thejns.org/toc/sup/121/Suppl.

Source: Le Roux R, Pollack CV, Milan M et al. Race against the clock: Overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage. J Neurosurg 2014; 121(Suppl):1–20.