Effect of oral anticoagulant use on surgical delay and mortality in hip fracture

Abstract

Aims Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically. Methods We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality). Results A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA. Conclusion Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222–233.

Do anticoagulants impact the “in-house mortality” after surgical treatment of proximal femoral fractures—a multivariate analysis

“…The inhouse mortality rate was 4% but showed a significant increase for patients on anticoagulants (7.7%) consistent with other studies showing increased mortality for anticoagulants [22] Dettoni et al were able to determine two main factors for increased mortality and complications, namely warfarin and a delay in time to surgery in a large cohort of 875 hip fractures [23]. DOACS were evaluated as a risk for higher mortality and delay to surgery also by a large metaanalysis [24]. Protocols for patients with anticoagulants have been established to enable early surgery [25].…”

Recommendations from the ICM-VTE: General

“…VKA inhibit hepatic production of the vitamin K dependent coagulation Factors (II, VII, IX, X), protein C and S. The clinical effect is measured by the INR. Previous studies have reported that the use of VKA was associated with a delay in time-to-surgery and higher mortality for patients requiring emergency orthopaedic procedures [1459][1460][1461][1462] . Furthermore, these patients experience increased surgical blood loss and higher risk of red blood cell transfusions 1463 , highlighting the importance reversing the anticoagulation effect prior to emergency surgery.…”

Preoperative leukocytosis and postoperative outcomes in geriatric hip fracture patients: a retrospective cohort study

“…The poorer outcome among men and those with declining mental function has been reported previously, [21][22][23] as has the worse outcome with hypoalbuminia [24][25][26] and usage of anticoagulation medication. 27 Hypoalbuminemia serves as a marker for malnutrition and increased inflammatory state, whereas usage of anticoagulation and antiaggregant medication is a marker for high cardiovascular risk and bleeding risk. Therefore, patients with those risk factors should be identified early and given additional care, such as dedicated expedited surgical protocols and nutritional support, in order to improve surgical outcome.…”