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Clinical Commentary |

American Association of Orthopedic Surgeons and American College of Chest Physicians Guidelines for Venous Thromboembolism Prevention in Hip and Knee Arthroplasty Differ: What Are the Implications for Clinicians and Patients?

John W. Eikelboom, MD; Ganesan Karthikeyan, MD; Nick Fagel, MD; Jack Hirsh, MD
Author and Funding Information

*From Department of Medicine, McMaster University (Drs. Eikelboom, Karthikeyan, and Hirsh); Population Health Research Institute, Hamilton Health Sciences and McMaster University (Drs. Eikelboom, Karthikeyan and Hirsh); Thrombosis Service, Hamilton General Hospital, McMaster University (Dr. Eikelboom); University of Amsterdam (Dr. Fagel); and Henderson Research Center (Dr. Hirsh), all located in Hamilton, ON, Canada.

Correspondence to: Jack Hirsh, MD, Henderson Research Centre, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada; e-mail: jhirsh@thrombosis.hhscr.org


Dr. Eikelboom has received consulting fees and/or honoraria from Astra-Zeneca, BI, BMS, Corgenix, Daiichi-Sankyo, Eisai, Eli-Lilly, GSK, Haemoscope, McNeil, and Sanofi-Aventis and has received grants and/or in-kind support from Accumetrics, AspirinWorks, Bayer, BI, BMS, Corgenix, Dade-Behring, GSK, and Sanofi-Aventis. Dr. Hirsh was the editor of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidenced-Based Clinical Practice Guidelines, 8th edition; he has no industry-related conflicts to report. None of the other authors have any disclosures.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(2):513-520. doi:10.1378/chest.08-2655
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The recently published American Association of Orthopedic Surgeons (AAOS) guidelines for the prevention of venous thromboembolism (VTE) in patients undergoing hip or knee surgery conflict with long-established and widely used American College of Chest Physicians (ACCP) guidelines. Both guidelines accepted that the most important goal of thromboprophylaxis in patients undergoing hip or knee replacement is to prevent pulmonary embolism (PE). The ACCP guidelines included asymptomatic (and symptomatic) deep vein thrombosis (DVT) detected by venography as a measure of the efficacy of thromboprophylaxis, whereas the AAOS rejected DVT as a valid outcome because the panelists considered the link between DVT and PE to be unproven. The AAOS position is inconsistent with evidence from imaging studies linking DVT with PE and from clinical studies demonstrating a parallel reduction of DVT and PE when antithrombotic agents are compared with placebo or untreated controls. The AAOS panel ignored the randomized data demonstrating that thromboprophylaxis reduces both DVT and PE, and many of their recommendations are based on expert opinion and lack a scientific basis. We recommend the ACCP guidelines because the methodology is explicit and rigorous and the treatment recommendations reflect all of the evidence from the randomized trials. Adoption of the ACCP guideline will ensure that patients undergoing hip and knee arthroplasty receive the best available therapies for prevention of VTE and reduce disability and death due to this common and potentially preventable condition.

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