EXTENDED THROMBOPROPHYLAXIS AFTER MAJOR ORTHOPEDIC SURGERY BASED ON CLINICAL ENDPOINTS. RISK PROFILE ANALYSIS NEEDED?

Abstract

According to the 2004 ACCP guidelines on antithrombotic and thrombolytic therapy general extended prophylaxis with low molecular weight heparins, vitamin K antagonists, or fondaparinux is recommended after major orthopedic surgery. This recommendation is based on a number of placebo controlled, clinical studies using venographic screening for deep vein thrombosis (DVT), as a surrogate end-point for pulmonary embolism (PE), other vascular thrombotic events were not considered. In a recent meta-analysis on these studies the overall event rate of symptomatic venous thromboembolism 30–42 days after a joint arthroplasty was 2.7% DVT and 0.6 % PE in patients having short-term prophylaxis and it was significantly reduced by extended prophylaxis. Bleeding episodes were seen in 4% of cases having extension. Taking into consideration the risk benefit for the individual patient do these findings justify that extended prophylaxis is used on a general basis? To answer this question also compliance, adverse event profile, and cost of the prophylactic regimens have to be addressed. It would be very attractive to be able to individualize the duration of the prophylactic period by assessing the thrombotic potential of every patient in order to balance the risks and benefits of continued prophylaxis.