PREVENTION OF VENOUS THROMBOEMBOLISM (VTE) FOLLOWING TOTAL HIP AND KNEE REPLACEMENT

NATIONAL GUIDELINE CLEARINGHOUSE™ (NGC)
GUIDELINE SYNTHESIS
PREVENTION OF VENOUS THROMBOEMBOLISM (VTE) FOLLOWING TOTAL HIP AND KNEE REPLACEMENT
GUIDELINES BEING COMPARED

American Academy of Orthopaedic Surgeons (AAOS). American Academy of Orthopaedic Surgeons clinical guideline on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2007. 63 p. [49 references]
http://www.guideline.gov/summary/summary.aspx?doc_id=10850&nbr=005665

American College of Chest Physicians (ACCP). Prevention of venous thromboembolism. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest 2008 Jun;133(6 Suppl):381S-453S. [728 references]
http://www.guideline.gov/summary/summary.aspx?doc_id=12956&nbr=006665


Committee on Perioperative Evaluation (CAPO), Brazilian Society of Cardiology (BSC). Steps to reduce surgical risk. In: I guidelines for perioperative evaluation. Arq Bras Cardiol 2007;89(6):e197-208.
http://www.guideline.gov/summary/summary.aspx?doc_id=12237&nbr=006322

TABLE OF CONTENTS
AREAS OF AGREEMENT AND DIFFERENCE
COMPARISON OF RECOMMENDATIONS

GENERAL RECOMMENDATIONS
MECHANICAL AND PHARMACOLOGIC THROMBOPROPHYLAXIS
STRENGTH OF EVIDENCE AND RECOMMENDATION GRADING SCHEMES
METHODOLOGY
SOURCE(S) OF FUNDING
BENEFITS AND HARMS
CONTRAINDICATIONS
ABBREVIATIONS

AREAS OF AGREEMENT AND DIFFERENCE
A direct comparison of recommendations presented in the above guidelines for prevention of VTE (DVT or PE) following total hip or knee replacement surgery is provided below.

Areas of Agreement
Postoperative Screening
Neither AAOS nor ACCP recommend routine screening for DVT or PE in asymptomatic patients postoperatively. According to AAOS, there is neither a sufficiently sensitive noninvasive screening tool nor a clearly established period of risk for VTE as to make routine screening reliably predictive or cost-effective in preventing PE. ACCP recommends against the routine use of DUS screening before hospital discharge. BSC does not address postoperative screening.

Areas of Difference
Mechanical and Pharmacological Prophylaxis
While all groups cite warfarin as an acceptable therapy in all patient groups, recommendations regarding other medications differ. Both ACCP and BSC recommend a LMWH (BSC specifies enoxaparin). ACCP also recommends fondaparinux; BSC does not. BSC recommends heparin for THR; ACCP does not.

AAOS, in contrast to ACCP, stratifies patients into four categories based on VTE risk and risk of major bleeding: standard VTE/standard bleeding risk; elevated VTE/standard bleeding risk; standard VTE/elevated bleeding risk; and elevated VTE/elevated bleeding risk. Warfarin is recommended for all four patient groups. Aspirin is recommended for all groups with the exception of the elevated VTE/standard bleeding risk group. LMWH and synthetic pentasaccharides are recommended for the standard VTE/standard bleeding risk group and the elevated VTE/standard bleeding risk group. No chemoprophylaxis is also cited as an option for patients at elevated risk of major bleeding. BSC stratifies patients into four categories based only on VTE risk: low risk; moderate risk; high risk; and very high risk.

Recommendations regarding mechanical prophylaxis differ slightly. According to AAOS, unless contraindicated, mechanical compression should be utilized for both total hip and knee arthroplasty for all patients in the recovery room and during the hospital stay. They also cite sole use of mechanical prophylaxis (no chemoprophylaxis) as an acceptable option in the two patient groups at elevated risk of bleeding. BSC also recommends mechanical prophylaxis for all patients, specifically IPC or compression stockings following THR, and IPC following TKR.

For patients undergoing THR or TKR, ACCP recommends the optimal use of mechanical thromboprophylaxis with the VFP or IPC for patients with a high risk of bleeding. When the high bleeding risk decreases, ACCP recommends that pharmacologic thromboprophylaxis be substituted for or added to the mechanical thromboprophylaxis. ACCP also cites the optimal use of IPC as an alternative option to anticoagulant thromboprophylaxis in patients undergoing TKR.

Initiation of Thromboprophylaxis
Recommendations regarding when to initiate LMWH and fondaparinux differ. For patients receiving LMWH, ACCP and BSC recommend starting therapy either preoperatively or postoperatively (at a usual high-risk dose [BSC specifies 40 mg sq], started 12 hours before surgery or 12 to 24 hours after surgery, or 4 to 6 hours after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day). AAOS, in contrast, recommends that administration of LMWH should begin 12 to 24 hours postoperatively (or after an indwelling epidural catheter has been removed).

With regard to fondaparinux, AAOS recommends initiation at 12 to 24 hours postoperatively (or after an indwelling catheter has been removed). ACCP, in contrast, recommends starting fondaparinux either 6 to 8 hours after surgery or the next day. BSC does not mention fondaparinux.

Duration of Thromboprophylaxis
For patients undergoing THR or TKR, ACCP recommends thromboprophylaxis with one of the recommended options (LMWH, fondaparinux [synthetic pentasaccharide], or a VKA) for at least 10 days and extending up to 35 days. AAOS, in contrast, recommends therapy with LMWH and synthetic pentasaccharides for 7 to 12 days, noting that the LMWHs and the synthetic pentasaccharides have not been sufficiently evaluated for longer periods to allow recommendation beyond this period. According to BSC, prophylaxis should last at least 7 days for THR and at least 7 to 10 days for TKR.

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http://www.guideline.gov/Compare/comparison.aspx?file=VTE1.inc