Dual Antiplatelet Therapy and Surgical Timing in Geriatric Hip Fracture

Tarrant, Seth M.; Kim, Raymond G.; McGregor, Kassandra L; Palazzi, Kerrin; Attia, John; Balogh, Zsolt J.

doi:10.1097/bot.0000000000001779

Cited by 12 publications

(7 citation statements)

References 27 publications

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“…Wound outcomes are important to surgeons, even if they are not serious adverse event. The external validity of these results must also be carefully applied: 65% of patients had an extracapsular fracture and 73% received fixationWhilst similar to our results in dual-antiplatelet agents and hip fracture [32], this is higher than the national average of 54% extracapsular fracture [20] and our control cohort. The posthoc calculation suggests this study lacks power.…”

Section: Discussionsupporting

confidence: 56%

Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

Tarrant

Catanach

Sarrami

et al. 2020

JCM

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Timely surgical intervention in hip fracture has been linked to improved outcomes. Direct Oral Anticoagulants (DOACs) are an emerging class of anticoagulants without evidence-based guidelines on surgical timing. This study aims to investigate how DOACs affect surgical timing and hence perioperative outcomes. A retrospective database/registry review was conducted for geriatric hip fracture patients aged 65 and over between 2011 and 2018. Primary outcome was 30-day mortality. Secondary outcomes included serious adverse events (SAE), transfusion and postoperative day (POD) 1 haemoglobin (Hb) levels. From a cohort of 3264 patients, 112 admitted subjects were taking DOACs; the annual proportion on DOACs increased over time. Mean time to surgery from last dose (Ts) was 2.2 (±1.0 SD) days. The primary outcome, 30-day mortality, occurred in 16 (14%) patients with secondary outcomes of SAEs in 25 (22%) patients and transfusion in 30 (27%) patients. Ts (days) did not significantly affect 30-day mortality (odds ratio (OR): 1.37, 95% confidence interval (CI): 0.80–2.33; p = 0.248), SAE (hazard ratio (HR): 1.03, 95% CI: 0.70–1.52; p = 0.885), transfusion (OR: 0.72 95% CI: 0.45 to 1.16; p = 0.177) or POD 1 Hb (OR: 1.99, 95% CI: −0.59 to 4.57; p = 0.129). Timing of surgery does not influence common surgical outcomes such as 30-day mortality, SAE, transfusion, and POD1 Hb in patients taking DOACs on admission.

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Section: Discussionsupporting

confidence: 56%

Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

Tarrant

Catanach

Sarrami

et al. 2020

JCM

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“…In a study of 122 patients on dual antiplatelet therapy at the time of hip fracture repair, there was a similar risk of transfusion, independent of time to operation. 34 Dual antiplatelet therapy was associated with a higher probability of major complications in early surgery. Delays to surgery for those on dual antiplatelet therapy led to higher mortality rate at 30 days.…”

Section: Recommendations On Dual Antiplatelet Therapymentioning

confidence: 99%

“…Delays to surgery for those on dual antiplatelet therapy led to higher mortality rate at 30 days. 34 It is unclear if the higher complication rate from early surgery was from blood loss or from the medical complications resulting from the fracture.…”

Section: Recommendations On Dual Antiplatelet Therapymentioning

confidence: 99%

Update on medical management of acute hip fracture

Ackermann

Schwenk

Lev

et al. 2021

CCJM

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H ip fractures are the most common reason for urgent surgery in the elderly and often lead to long-term institutional care. 1 Despite advances in perioperative management, postoperative mortality rates remain high, up to 10% in the fi rst 30 days and 8% to 36% in the fi rst year after repair. 2 Even 10 years after fracture repair, the mortality rate due to comorbid medical conditions remains higher than in age-matched controls. 3

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“…We identified 18 publications that met the inclusion criteria, all of which were observational. Two of these [ 21 , 22 ] were propensity-matched for patient characteristics such as age, sex, comorbidities, severity of surgical disease, and surgical approach. The majority of the studies were single-institution designs ( N = 14).…”

Section: Resultsmentioning

confidence: 99%

Dual antiplatelet management in the perioperative period: updated and expanded systematic review

Premji,

Blegen,

Corley

et al. 2023

Syst Rev

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Background Antiplatelet agents are central in the management of vascular disease. The use of dual antiplatelet therapy (DAPT) for the management of thromboembolic complications must be weighed against bleeding risk in the perioperative setting. This balance is critical in patients undergoing cardiac or non-cardiac surgery. The management of patients on DAPT for any indication (including stents) is not clear and there is limited evidence to guide decision-making. This review summarizes current evidence since 2015 regarding the occurrence of major adverse events associated with continuing, suspending, or varying DAPT in the perioperative period. Methods A research librarian searched PubMed and Cochrane from November 30, 2015 to May 17, 2022, for relevant terms regarding adult patients on DAPT for any reason undergoing surgery, with a perioperative variation in DAPT strategy. Outcomes of interest included the occurrence of major adverse cardiac events, major adverse limb events, all-cause death, major bleeding, and reoperation. We considered withdrawal or discontinuation of DAPT as stopping either aspirin or a P2Y12 inhibitor or both agents; continuation of DAPT indicates that both drugs were given in the specified timeframe. Results Eighteen observational studies met the inclusion criteria. No RCTs were identified, and no studies were judged to be at low risk of bias. Twelve studies reported on CABG. Withholding DAPT therapy for more than 2 days was associated with less blood loss and a slight trend favoring less transfusion and surgical re-exploration. Among five observational CABG studies, there were no statistically significant differences in patient death across DAPT management strategies. Few studies reported cardiac outcomes. The remaining studies, which were about procedures other than exclusively CABG, demonstrated mixed findings with respect to DAPT strategy, bleeding, and ischemic outcomes. Conclusion The evidence base on the benefits and risks of different perioperative DAPT strategies for patients with stents is extremely limited. The strongest signal, which was still judged as low certainty evidence, is that suspension of DAPT for greater than 2 days prior to CABG surgery is associated with less bleeding, transfusions, and re-explorations. Different DAPT strategies’ association with other outcomes of interest, such as MACE, remains uncertain. Systematic review registration A preregistered protocol for this review can be found on the PROSPERO International Prospective Register of systematic reviews (http://www.crd.york.ac.uk/PROSPERO/; registration number: CRD42022371032).

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Dual Antiplatelet Therapy and Surgical Timing in Geriatric Hip Fracture

Cited by 12 publications

References 27 publications

Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

Update on medical management of acute hip fracture

Dual antiplatelet management in the perioperative period: updated and expanded systematic review

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