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Stockings plus anticoagulation more effective to prevent post-op VTE, but anticoagulation increases bleeding

Clinical Question:
Is the combination of compression stockings and anticoagulants more effective in preventing postoperative venous thromboembolic events than either alone?

Bottom Line:
In general, the combination of compression stockings and anticoagulants given postoperatively decreases the rate of venous thromboembolic events (VTE), but not necessarily symptomatic deep vein thrombosis (DVT). Adding anticoagulants to compression stockings also increases the rate of bleeding. (LOE = 1a)

Reference:
Zareba P, Wu C, Agzarian J, Rodriguez D, Kearon C. Meta-analysis of randomized trials comparing combined compression and anticoagulation with either modality alone for prevention of venous thromboembolism after surgery. Br J Surg 2014;101(9):1053-1062.  [PMID:24916118]

Study Design:
Meta-analysis (randomized controlled trials)

Funding:
Unknown/not stated

Setting:
Various (meta-analysis)

Synopsis:
These authors systematically searched several databases to identify randomized trials that compared the addition of compression stockings to anticoagulant therapy, and vice versa, for the prevention of VTE in postoperative patients. Two authors independently assessed studies for inclusion and resolved disagreements by consensus. Additionally, 2 authors independently extracted data and assessed the quality of each study. Ultimately, they included 11 studies (4866 patients) that compared compression stockings plus anticoagulants versus anticoagulants alone, and 17 studies (4673 patients) that compared compression stockings plus anticoagulants versus stockings alone. The studies that compared the addition of compression stockings were generally of low quality; those that compared the addition of anticoagulants were of moderate quality. Compression stockings plus anticoagulants versus anticoagulants alone: In these studies, the rate of DVT was approximately 5% for the combined therapy versus 10% for anticoagulation alone (number needed to treat [NNT] = 19, 95% CI, 13 - 34). Only 4 of the studies reported on the rate of symptomatic DVT and found no difference between the groups. Only 9 studies reported on pulmonary embolism: The overall rate was only 2.5%; adding compression stockings to anticoagulants decreased the rate by about half. Compression stockings plus anticoagulants versus compression stockings alone: In these studies, the rate of DVT was approximately 7% for the combined therapy versus 13% for stockings alone (NNT = 17; 95% CI, 13 - 24). Similarly, though, there was no significant difference in the rate of symptomatic DVT. Additionally, adding anticoagulants to compression stockings did not decrease the rate of pulmonary emboli. The rate of bleeding was almost doubled when adding anticoagulants (6.5% vs 3.4%; number needed to treat to harm = 33; 95% CI, 24 - 57).

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