Aspirin Matches Rivaroxaban for Blood Clot Prevention After Joint Replacement, Suggests Study
Canada: The EPCAT III randomized trial has found that an aspirin-only regimen was as effective and safe as rivaroxaban for preventing symptomatic venous thromboembolism (VTE) after total hip or knee arthroplasty. There was no clinically significant difference in bleeding risk between the two strategies, supporting aspirin as a simpler and more cost-effective option for postoperative thromboprophylaxis in patients at standard risk.
The findings, published in the New England Journal of Medicine, come from a multicenter, double-blind, randomized controlled trial led by Sudeep Shivakumar from the Department of Medicine, Dalhousie University, Halifax, Canada, and colleagues.
Venous thromboembolism, including deep-vein thrombosis and pulmonary embolism, remains a major complication after total hip and knee replacement surgery. Although direct oral anticoagulants such as rivaroxaban are widely used for thromboprophylaxis, aspirin has emerged as a less expensive and easier-to-administer alternative. Previous studies demonstrated the safety of aspirin following an initial short course of rivaroxaban, but evidence supporting aspirin alone from the immediate postoperative period has been limited.
To address this question, the investigators enrolled 5,429 patients undergoing total hip or total knee arthroplasty across multiple centers. Participants were randomly assigned to receive either 81 mg of aspirin once daily or 10 mg of oral rivaroxaban once daily during the first five days after surgery. After this initial period, all patients received 81 mg of aspirin daily, continuing for an additional nine days following knee replacement or 30 days following hip replacement.
Participants were followed for 90 days to assess the occurrence of symptomatic venous thromboembolism, defined as proximal deep-vein thrombosis or pulmonary embolism, as well as major or clinically relevant nonmajor bleeding events.
The study reported the following key findings:
- Symptomatic venous thromboembolism occurred in 0.48% of patients receiving aspirin alone compared with 0.45% of those treated with rivaroxaban followed by aspirin.
- Aspirin alone met the predefined noninferiority criteria, demonstrating comparable effectiveness in preventing postoperative VTE.
- Major bleeding or clinically relevant nonmajor bleeding occurred in 1.66% of patients in the aspirin-alone group and 2.04% of those in the rivaroxaban–aspirin group.
- No clinically meaningful difference in bleeding risk was observed between the two treatment strategies.
The findings suggest that initiating thromboprophylaxis with aspirin immediately after surgery protects against postoperative blood clots comparable to that achieved with rivaroxaban, without increasing bleeding complications.
The researchers concluded that aspirin alone was noninferior to rivaroxaban followed by aspirin for preventing symptomatic venous thromboembolism after total hip and knee arthroplasty. They noted that the comparable efficacy and safety profiles support aspirin as a practical, accessible, and cost-effective thromboprophylaxis strategy for patients undergoing joint replacement surgery who are at standard risk for postoperative venous thromboembolism.
Reference:
DOI: 10.1056/NEJMoa2603649
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