• Ignacio Neumann, Gabriel Rada, Juan Carlos Claro, Alonso Carrasco-Labra, Kristian Thorlund, Elie A Akl, Shannon M Bates, and Gordon H Guyatt.
• McMaster University Health Sciences Centre, Clinical Epidemiology & Biostatistics, Room 2C12, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada. ignacio.neumann@gmail.com
• Ann. Intern. Med. 2012 May 15;156(10):710-9.

BackgroundThromboembolic disease is the most frequent medical complication of arthroplasty.PurposeTo evaluate the benefits and harms of oral direct factor Xa inhibitors versus low-molecular-weight heparin (LMWH) in patients undergoing total hip or knee replacement.Data SourcesMEDLINE (1966 to December 2011), EMBASE (1980 to December 2011), and the Cochrane Central Register of Controlled Trials (up to December 2011), without language restrictions. References of reviews and abstracts of conferences were hand-searched.Study SelectionRandomized trials in patients undergoing hip or knee replacement that evaluated factor Xa inhibitors versus LMWH.Data ExtractionTwo reviewers independently evaluated eligibility, abstracted the data, and assessed risk for bias.Data SynthesisIn 22 trials, high-quality evidence indicated that the absolute effect of factor Xa inhibitors and LMWH does not differ in terms of all-cause mortality (risk difference, 0 fewer deaths per 1000 patients [95% CI, 2 fewer to 1 more death]) or nonfatal pulmonary embolism (risk difference, 0 fewer events per 1000 patients [CI, 1 fewer to 2 more events]). Factor Xa inhibitors can prevent 4 instances of symptomatic deep venous thrombosis per 1000 treated patients (CI, 3 to 6 fewer events; high-quality evidence) but may increase major bleeding by 2 more events per 1000 patients (CI, 0 to 4 more events; moderate-quality evidence). High, but not lower, doses of oral factor Xa inhibitors increased bleeding compared with LMWH.LimitationsMost trials did not report outcome data for a substantial proportion of the patients. In 9 trials, the follow-up period was 14 days or less.ConclusionCompared with LMWH, lower doses of oral factor Xa inhibitors can achieve a small absolute risk reduction in symptomatic deep venous thrombosis without increasing bleeding.

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