Objectives: To determine how preoperative direct oral anticoagulant (DOAC) use affects rates of blood transfusion, clinically important blood loss, and 30-day mortality in patients with hip fracture undergoing surgery within 48 hours of presentation to the emergency department. Design: Retrospective cohort study. Setting: Academic trauma center. Patients: A total of 535 patients with hip fracture who underwent open cephalomedullary nail fixation or arthroplasty either taking a direct oral anticoagulant or no form of chemical anticoagulant/antiplatelet agent before presentation (control). Main Outcome Measures: Demographics, time to surgery, type of surgery, blood transfusion requirement, clinically important blood loss, and 30-day mortality. Results: Forty-one patients (7.7%) were taking DOACs. DOAC patients were older (81.7 vs. 77 years, P = 0.02) and had higher BMI (26.9 vs. 24.2 kg/m 2 , P = 0.01). Time from admission to surgery was similar between DOAC users (20.1 hours) and the control (18.7 hours, P > 0.4). There was no difference in receipt of blood transfusion ( P = 0.4), major bleeding diagnosis ( P = 0.2), acute blood loss anemia diagnosis ( P = 0.5), and 30-day mortality ( P = 1) between the DOAC and control group. This was true when stratifying by type of surgery as well. Conclusions: Our results suggest that early surgery may be safe in patients with hip fracture taking DOACs despite theoretical risk of increased bleeding. Because early surgery has previously been associated with decreased morbidity and mortality, we suggest that hip fracture surgery should not be delayed because a patient is taking direct oral anticoagulants. Level of Evidence: Prognostic Level III.

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