阿司匹林预防全髋或全膝置换术后深静脉血栓形成的循证医学进展

State-of-the-Art evidence-based review of aspirin for thromboprophylaxis in modern elective total hip and kneearthroplasty

目的探讨阿司匹林预防全髋置换术(THA)或全膝置换术(TKA)后深静脉血栓形成(DVT)的循证医学研究证据。方法检索英国国家医疗服务体系(National Health Service,NHS)数据库、研究转化临床实践(Turning Research into practice,TRIP)医学数据库、系统性评价Cochrane数据库、OVID、Web of science、MEDLINE以及EMBASE数据库2004年1月至2017年9月发表的关于阿司匹林预防THA或TKA术后DVT的随机对照研究(RCT)文章,评价临床疗效主要转归结果是任何形式的DVT,次要转归结果是伤口并发症(伤口延迟渗出、感染)。结果共纳入14篇文章,其中5篇I级研究证据的文章,9篇Ⅲ级研究证据;证据级别高的1篇RCT文章研究结果显示:阿司匹林与低分子肝素相比,TKA术后DVT发生率差异无统计学意义;目前支持阿司匹林相较低分子肝素、华法林或者达比加群酯对THA或TKA术后DVT预防效果要差的证据尚不充分;与阿司匹林相比,利伐沙班可以使得TKA或THA术后的无症状DVT发生率下降,但是否能够预防有症状的DVT,目前证据尚且不足;与阿司匹林相比,THA或TKA术后使用达比加群酯和利伐沙班伤口并发症要更高。结论目前临床研究证据表明,除了当前的利伐沙班及低分子肝素抗凝药物外,阿司匹林也许能成为THA或TKA术后DVT预防的另一选择。

Objective There is uncertainty regarding the optimal means of thromboprophylaxisfollowing total hip and knee arthroplasty （THA, TKA）. This systematic evidence-based review presents theevidence for acetylsalicylic acid （aspirin） as a thromboprophylactic agent in THA and TKA and compares itwith other chemoprophylactic agents. Methods A search of literature published between January 2004 andSeptember 2017 was performed in the database including NHS、TRIP、Cochrane, MEDLINE and EMBASEin accordance with Preferred Reporting Items for Systematic Reviews and Meta- Analyses guidelines.Results A total of 14 studies were eligible for inclusion including 5 level I evidence studies and 9 level Ⅲevidence studies; Evidence from one good quality randomized controlled trial （RCT） showed no differencein rates of venous thrombo- embolism （VTE） in patients given aspirin or low molecular weight heparin（LMWH） following TKA. There was insufficient evidence from trials with moderate to severe risk of biasbeing present to suggest aspirin is more or less effective than LMWH, warfarin or dabigatran for theprevention of VTE in TKA or THA. Compared with aspirin, rates of asymptomatic deep vein thrombosis（DVT） in TKA may be reduced with rivaroxaban but insufficient evidence exists to demonstrate an effect onincidence of symptomatic DVT. Compared with aspirin there is evidence of more wound complicationsfollowing THA and TKA with dabigatran and in TKA with rivaroxaban. Conclusions The results suggestaspirin may be a suitable alternative to other thrombo prophylactic agents following THA and TKA. Furtherinvestigation is required to fully evaluate the safety and efficacy of aspirin.