Rivaroxaban verlaagt DVT-risico na gewrichtsvervanging, maar verhoogt bloedingen

Deep vein thrombosis (DVT) is a major concern following total hip arthroplasty (THA) and total knee arthroplasty (TKA), with prophylactic anticoagulation being the cornerstone of postoperative care. This multicenter retrospective cohort study evaluated the relative effectiveness and safety of rivaroxaban and low molecular weight heparin (LMWH) in DVT prevention after joint replacement surgery. It also aimed to identify patient-related risk factors for thrombotic and hemorrhagic events. It was hypothesized that rivaroxaban would reduce DVT incidence compared with LMWH but may increase bleeding risk, and that patient-specific factors would influence these outcomes. The study included 32,512 patients undergoing elective TKA or THA. Categorization of patients was based on the postoperative anticoagulation strategy, and propensity scores were used to match them using nearest-neighbor propensity score matching based on baseline covariates, including age, sex, body mass index, smoking status, comorbidities (e.g., diabetes, prior venous thromboembolism [VTE]), American Society of Anesthesiologists (ASA) class, and type of surgery (THA/TKA). All patients underwent standardized duplex ultrasonography to detect DVT. Results showed that rivaroxaban was less likely to be associated with DVT at 30 days than LMWH (2.3% vs. 3.6%) with an adjusted odds ratio of 0.62 (p < 0.001). These values represent the cumulative incidence of DVT within 30 days postoperatively. However, rivaroxaban use was associated with a higher incidence of major bleeding (1.48% vs. 1.08%) and a postoperative hemoglobin drop. No significant differences were observed in 30-day pulmonary embolism (PE), readmissions, or mortality between the two groups. Subgroup analysis demonstrated benefit across key patient groups, including obese, elderly, diabetic, and TKA patients. Multivariable modeling established that pre-existing VTE, obesity, and age above 75 years were predictors of DVT, whereas baseline anemia and rivaroxaban use were independent predictors of major bleeding. These findings highlight the need for individualized prophylaxis strategies that balance thrombotic and hemorrhagic risks in patients undergoing major joint arthroplasty.