Aspirin Is as Effective and Safe as Oral Anticoagulants for Venous Thromboembolism Prophylaxis After Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Abstract

Background: Joint arthroplasty effectively treats osteoarthritis, providing pain relief and improving function, but postoperative venous thromboembolism (VTE) remains a common complication. This study therefore assessed the effectiveness and safety of aspirin compared with oral anticoagulants (OACs) for VTE prophylaxis after joint arthroplasty.

Methods: A systematic review and meta-analysis was performed by searching PubMed, Embase, the Web of Science, and the Cochrane Library for randomized controlled trials (RCTs) up to May 14, 2024, that compared the effect of aspirin versus OACs on VTE prophylaxis in adults undergoing joint arthroplasty. Data extraction followed the PRISMA guidelines. Two independent researchers conducted the literature searches and data extraction. A random-effects model was used to estimate effects. The primary outcome was the incidence of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE); secondary outcomes included bleeding, wound complications, and mortality.

Results: The meta-analysis included 11 RCTs with a total of 4,717 participants (55.1% female) from several continents. The relative risk (RR) of VTE following joint arthroplasty was 1.11 (95% confidence interval [CI], 0.93 to 1.32) for aspirin compared with OACs. Similar results were observed for DVT (RR, 1.12; 95% CI, 0.90 to 1.40) and PE (RR, 1.18; 95% CI, 0.51 to 2.71). There were no significant differences in the risks of bleeding, wound complications, or mortality between patients receiving aspirin and those receiving OACs. Subgroup analyses considering factors such as study region, type of joint surgery, type of VTE detection, year of publication, use of mechanical VTE prophylaxis, aspirin dose, type of OAC comparator, study quality, and funding also found no significant differences in VTE incidence between aspirin and OACs. The overall quality of evidence for VTE and DVT outcomes was high.

Conclusions: Based on high-quality evidence from RCTs, aspirin is as effective and safe as OACs in preventing VTE, including DVT and PE, after joint arthroplasty, without increasing complications.

Level of evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Fig. 1

Flow diagram for the search and selection of included studies.

Fig. 2

Risk-of-bias summary: the review authors’ judgments regarding each risk-of-bias item for each included study.

Fig. 3

Effectiveness of aspirin compared with oral anticoagulants with respect to the rate of venous thromboembolism (deep vein thrombosis plus pulmonary embolism) in randomized controlled trials of patients undergoing joint arthroplasty.

Fig. 4

Effectiveness of aspirin (ASA) compared with oral anticoagulants with respect to the rate of venous thromboembolism (VTE) in randomized clinical trials of patients undergoing joint arthroplasty, grouped according to study-level characteristics. DVT = deep vein thrombosis, PE = pulmonary embolism, RA = rivaroxaban, IPC = intermittent pneumatic compression.

Fig. 5

Safety of aspirin compared with oral anticoagulants with respect to the rate of complications in randomized controlled trials of patients undergoing joint arthroplasty. GI = gastrointestinal.

Fig. 6

Funnel plot for publication bias in studies reporting VTE rates. se = standard error.