Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study

Abstract

BACKGROUND:While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS:This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS:Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups.After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION:Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use.

Warfarin, not direct oral anticoagulants or antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: Implications in this new era of novel anticoagulants: An EAST multicenter study

“…These findings are in contrast to the results of the previous study using this same cohort. 6 This difference in results can be attributed to the potential limitation of combining patients on warfarin or AP therapy into one cohort, given their distinct mechanisms of action and variations in the availability and efficacy of reversal agents. The results of this study further support that presumption.…”

“…This was a post hoc secondary analysis of the Eastern Association for the Surgery of Trauma prospective, observational multicenter Anticoagulation in Emergency Surgery (ACES) trial. 6 Data were collected across 21 trauma centers (16 Level 1, 4 Level 2, and 1 Level 3) between June, 2019 and January, 2022. All collaborating centers obtained individual local institutional review board approval before participation.…”

“…Our results showed that there was no difference in perioperative bleeding complications between DOACs versus the combined traditional therapy cohort. 6 However, AP and warfarin therapy have distinct mechanisms of action and variations in the availability and effectiveness of reversal agents. This is further supported by several studies showing a trend toward a higher bleeding risk in patients on warfarin compared with AP therapy.…”