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Perioperative antithrombotic management in joint replacement surgeries
1Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong.
Insights
Optimal perioperative antithrombotic management for cardiac patients undergoing joint replacement surgery requires balancing arterial and bleeding risks. Stratify patients by arterial thromboembolism risk to guide antiplatelet or anticoagulant therapy decisions.
Area of Science:
- Cardiology
- Orthopaedic Surgery
- Pharmacology
Background:
- Patients with cardiac diseases often require antithrombotic agents.
- Joint replacement surgery poses risks of arterial and venous thromboembolism.
- Perioperative management requires careful consideration of antithrombotic therapy.
Purpose of the Study:
- To determine optimal perioperative antithrombotic management strategies.
- To guide the use of antiplatelet and anticoagulant agents in cardiac patients undergoing joint replacement.
- To review current evidence on managing thromboembolic risks in this population.
Main Methods:
- Comprehensive literature search of MEDLINE and PubMed databases up to January 2013.
- Inclusion of studies on perioperative antithrombotic management in orthopaedic and general surgery.
- Review of original articles and best practice guidelines.
Main Results:
- Stratify patients by arterial thromboembolism risk to select appropriate perioperative regimens.
- Defer surgery for 6 weeks after bare-metal stenting and 6 months after drug-eluting stenting.
- Adjust aspirin dosage or add low-molecular-weight heparin for venous thromboembolism prophylaxis.
Conclusions:
- Perioperative management involves balancing arterial thromboembolism risk against bleeding risk.
- Judicious selection of antithrombotic regimens is crucial.
- Optimal venous thromboembolism prophylaxis for patients on aspirin remains under debate.
Objectives:
To determine optimal perioperative antithrombotic management for patients with cardiac diseases undergoing joint replacement surgeries.
Data Sources:
MEDLINE and PubMed database search up to January 2013.
Study Selection:
Those dealing with perioperative antithrombotic management of patients undergoing orthopaedic operations, especially joint replacement, and also those undergoing general surgery. Various combinations of the following key words were used in our search: "antiplatelet", "antithrombotic", "anticoagulant", "coronary stent", "perioperative", "venous thromboembolism", "cardiovascular", "surgery", "orthopaedic", "knee replacement", "hip replacement", "joint replacement", and "arthroplasty".
Data Extraction:
Literature review, original articles, and best practice guidelines.
Data Synthesis:
Patients should be stratified according to their risk of developing arterial thromboembolism in order to decide the most appropriate perioperative antiplatelet or anticoagulant regimen for them. After recent coronary stenting, including bare-metal stents implanted within 6 weeks and drug-eluting stents implanted within 6 months, surgery should be deferred. For venous thromboembolism prophylaxis in patients already on aspirin, the dosage should be adjusted as necessary or additional low-molecular-weight heparin administered.
Conclusion:
The perioperative management of patients with cardiac diseases in receipt of antithrombotic agents is based upon a delicate balance between the perceived risk of arterial thromboembolism and the perceived risk of perioperative bleeding. One must exercise good judgement in deciding the most appropriate perioperative antithrombotic regimen. Venous thromboembolism is also a common problem after joint replacement surgeries. For patients already on aspirin, optimal venous thromboembolism prophylaxis is still being debated.
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