Cardiovascular Complications After Joint Replacement Surgery: A Crossroad in Anticoagulation Vincent...
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Transcript of Cardiovascular Complications After Joint Replacement Surgery: A Crossroad in Anticoagulation Vincent...
Cardiovascular Complications After Joint Replacement Surgery:
A Crossroad in Anticoagulation
Vincent D. Pellegrini Jr, MDProfessor and Chair
Department of Orthopedic Surgery Medical University of South Carolina
Charleston, South Carolina
Moderator:Samuel Z. Goldhaber, MD
Professor of MedicineHarvard Medical School
DirectorVenous Thromboembolism Research Group
Staff CardiologistBrigham and Women's Hospital
Boston, Massachusetts
Panelists:Kevin J. Bozic, MD, MBA
William R. Murray ProfessorVice Chair
Department of Orthopaedic Surgery University of California, San Francisco
..
Timing of MI Following THR/TKR Surgery: A Nationwide Cohort Study
Cumulative incidence rates of AMI:A: Patients undergoing THR B: Patients undergoing TKR
66,524 patients with THR, 28,703 patients with TKR, and 286,165 matched controls 99.1% had received thromboprophylaxis; 93%, LMWH. Study done in Denmark.
Risk of AMI is substantially increased in the first 2 weeks after THR (25-fold) and TKR (31-fold) surgery compared with controls.
Lalmohamed A, et al.[1]
IMAGES NO LONGER AVAILABLE
ASA Physical Status Classification System
American Society of Anesthesiologists.[2]
ASA Physical Status
Description
1 A normal healthy patient
2 A patient with mild systemic disease
3 A patient with severe systemic disease
4 A patient with severe systemic disease that is a constant threat to life
5 A moribund patient who is not expected to survive without the operation
6 A patient declared brain-dead whose organs are being removed for donor purposes
Minimizing CV Risk
• Principal advancement in joint replacement surgery has
been improvement in anesthetic techniques, especially
the use of regional anesthesia
• Stratify perioperative risk and ensure all modifiable risk
factors have been optimized
VTE Prevalence After Major Orthopaedic Surgery Without Prophylaxis
Procedure DVT(Total, %)
PE(Total, %)
Fatal PE(%)
Total hip replacement
42-57 0.9-28 0.1-2.0
Total knee replacement
41-85 1.5-10 0.1-1.7
Geerts, WH, et al.[3]
…
Types of VTE Prophylaxis: 2008 Survey
Anderson FA, et al.[5]
Rivaroxaban (FDA-approved)
•RECORD1: Rivaroxaban 10 mg vs enoxaparin 40 mg for 5 weeks, THRa
•RECORD2: Rivaroxaban 10 mg for 5 weeks vs enoxaparin 40 mg for 10-14 days, THRb
•RECORD3: Rivaroxaban 10 mg vs enoxaparin 40 mg for 13-17 days, TKRc
•RECORD4: Rivaroxaban 10 mg vs enoxaparin 30 mg every 12 hours for 17 days, TKRd
a. Eriksson BI, et al.[6]
b. Kakkar AK, et al.[7] c. Lassen MR, et al.[8] d. Turpie AG, et al.[9]
Novel Oral Anticoagulants: Trials in Major Orthopaedic Surgery
Apixaban: Pooled Results of ADVANCE-2 and ADVANCE-3N = 8464 patients undergoing TKR (ADVANCE-2) and THR (ADVANCE-3)Not FDA approved for use in major orthopaedic surgery
Raskob GE, et al.[10]
Apixaban Enoxaparin
Risk Difference(95% CI)
P Value
Efficacy
Major VTE, % 0.7 1.5 -0.8(-1.2 to -0.3) .001
Safety
Major bleeding, % 0.7 0.8 -0.02(-0.4 to 0.4) --
Clinically relevant nonmajor bleeding, % 3.6 4.2 -0.6
(-1.4 to 0.3) --
Dabigatran: RE-MOBILIZE, RE-MODEL, RE-NOVATE: Pooled AnalysisNot FDA approved for use in major orthopaedic surgery
EnoxaparinDabigatran
150 mg Dabigatran
220 mg
EfficacyP Value P Value
Major VTE and VTE-related Mortality, %
3.3 3.8 .91 3.0 .20
Safety
Major bleeding, % 1.4 1.1 0.16 1.4 .61
Major + clinically relevant nonmajor bleeding 5.0 5.6 .58 5.6 .56
Friedman RJ, et al.[11]
N = 12,729 RivaroxabanEnoxapari
n
Hazard Ratio
(95% CI)P
Value
Efficacy
Composite of symptomatic VTE + all-cause mortality, % 0.5 1 0.48
(0.30-0.76) .001
Safety: Bleeding Events
Major bleeding, % 0.3 0.2 1.62(0.77-1.53) .23
Major + clinically relevant nonmajor bleeding, % 2.8 2.5 1.17
(0.93-1.46) .19
Turpie AGG, et al.[12]
RECORD 1-4: Pooled Analysis
Rivaroxaban Enoxaparin
Hazard Ratio
(95% CI) P Value
Bleeding Events*
Major bleeding 0.3% 0.2% 1.62(0.77-1.53)
.23
Major + non-major clinically relevant bleeding 2.8% 2.5% 1.17
(0.93-1.46).19
Any bleeding 6.6% 6.2% 1.07(0.92-1.24)
.38
Turpie AG, et al.[12]
*Day 12 ± 2 active treatment pool.
RECORD 1-4: Pooled Analysis - Safety
Enoxaparin
Rivaroxaban
RECORD Study Design
Mandatorybilateralvenography
R
SURGERY
FOLLOWUP
Evening before surgery
Day 1
Double blind
Last dose, daybefore venography
6-8 hours postsurgery
Turpie AGG, et al.[12]
Summary
• Patients undergoing major orthopaedic surgery are at
high risk for developing VTE/PE.
• Effective prophylaxis reduces this risk considerably.
• As new agents become more widely used, the use of
the older oral anticoagulants, including LMWH and
warfarin, is declining.
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