DOACs may prevent symptomatic VTE better than heparin after noncardiac surgery
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For prevention of venous thromboembolism after noncardiac surgery, direct oral anticoagulants may be preferred over low-molecular-weight heparin, according to a systematic review and meta-analysis.
Direct oral anticoagulants (DOACs), low-dose low-molecular-weight heparin (LMWH) and high-dose LMWH all reduced risk for symptomatic VTE and increased risk for major bleeding compared with no treatment, but DOACs reduced symptomatic VTE without increasing bleeding compared with low-dose LMWH, the researchers wrote in The BMJ.
Maura Marcucci, MD, MSc, assistant professor in the departments of medicine and health research methods, evidence and impact and attending physician in the divisions of general internal medicine and perioperative care at McMaster University in Hamilton, Ontario, Canada, and colleagues analyzed 68 randomized controlled trials of 45,445 patients who underwent noncardiac surgery; 51 of the trials pertained to orthopedic surgery.
Most of the trials compared low-dose LMWH with no active treatment (placebo or no treatment) or with DOACs, according to the researchers.
Compared with no active treatment, low-dose LMWH (OR = 0.33; 95% CI, 0.16-0.67), high-dose LMWH (OR = 0.19; 95% CI, 0.07-0.54) and DOACs (OR = 0.17; 95% CI, 0.07-0.41) all reduced risk for symptomatic VTE, with absolute risk differences of 1 to 100 per 1,000 patients, the researchers wrote.
All three anticoagulation strategies were associated with increased risk for major bleeding compared with no active treatment (P = .002 for low-dose LMWH; P = .004 for high-dose LMWH; P = .04 for DOACs), according to the researchers.
DOACs conferred reduced risk for symptomatic VTE compared with low-dose LMWH (OR = 0.53; 95% CI, 0.32-0.89; P = .02) but not with high-dose LMWH (OR = 0.93; 95% CI, 0.51-1.71), Marcucci and colleagues found.
In addition, they found, DOACs did not increase risk for major bleeding compared with low-dose LMWH (OR = 1.23; 95% CI, 0.89-1.69).
Compared with low-dose LMWH, high-dose LMWH did not lower symptomatic VTE risk (OR = 0.57; 95% CI, 0.26-1.27) but raised risk for major bleeding (OR = 1.87; 95% CI, 1.06-3.31), according to the researchers.
None of the active treatments conferred reduced risk for symptomatic pulmonary embolism compared with no active treatment, the researchers wrote.
“Direct oral anticoagulants and low-molecular-weight heparin reduced venous thromboembolism compared with no active treatment but probably increased major bleeding to a similar extent,” Marcucci and colleagues wrote. “Direct oral anticoagulants probably prevent symptomatic venous thromboembolism to a greater extent than prophylactic low-molecular-weight heparin.”
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