Effect of oral anticoagulants on hemostatic and thromboembolic complications in hip fracture: A systematic review and meta‐analysis

Abstract

Background: Hip fracture patients on oral anticoagulants (OACs) experience increased time-to-surgery and higher mortality compared to non-anticoagulated patients. However, it is unclear whether pre-injury OAC status and its associated operative delay are associated with worsening of peri-operative hemostasis or an increased risk of postoperative thromboembolism. Methods: We performed a systematic review to identify studies that directly compared hemostatic and thromboembolic outcomes among hip fracture patients on an OAC prior to admission with those not on anticoagulants. Random effects metaanalyses were used to pool all outcomes of interest (estimated blood loss, transfusion requirements, and postoperative thromboembolism). Results: Twenty-one studies involving 21 417 patients were included. Estimated blood loss was higher among patients presenting with OACs compared to those not anticoagulated (mean difference 31.0 mL, 95% confidence interval [CI] 6.2-55.7). Anticoagulated patients also had a 1.3-fold higher risk of receiving red blood cell transfusions (odds ratio [OR] 1.34, 95% CI 1.20-1.51); however, rates of postoperative thromboembolism were similar regardless of anticoagulation status (OR 0.96, 95% CI 0.40-2.79 for venous thromboembolism; OR 0.58, 95% CI 0.25-1.36 for arterial thromboembolism). No subgroup effect was found based on anticoagulant type or degree of surgical delay. Conclusion: Hip fracture patients on OACs experience increased surgical blood loss and higher risk of red blood cell transfusions. However, the degree of surgical delay did not mitigate this risk, and there was no difference in postoperative thromboembolism. The impact of appropriate, timely OAC reversal on blood conservation and expedited surgery in anticoagulated hip fracture patients warrants urgent evaluation. | 2567 XU et al.

Recommendations from the ICM-VTE: General

“…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.…”

Orthogeriatric Care: Reviewing Improvements in Outcomes

“…It should be noted that the degree of surgical delay did not mitigate this bleeding risk, and there was no difference in the rate of postoperative thromboembolism, either. No subgroup effect was found based on anticoagulant type or degree of surgical delay [134].…”

“…However, Leer-Salvensen reported a 5-fold increase in the rate of wound haematomas, though without complications [139]. Conversely, other studies such as the meta-analysis by Xu et al [134] and other cohort studies observed that DOACs were associated with a slightly increased risk of intra-operative bleeding and blood transfusion [141,142]. This association remained when including only patients operated on in less than 24 hours [142].…”

“…Patients on oral anticoagulants (VKA, DOACs) with hip fracture experience a small increase of surgical blood loss (mean difference 31.0 mL, 95% CI: 6.2-55.7) and have 1.3-fold higher risk of receiving red blood cell transfusions (OR: 1.34, 95% CI 1.20-1.51) according to a recent meta-analysis [134]; rates of postoperative thromboembolism were similar regardless of anticoagulation status, for venous as well as arterial thromboembolism (OR 0.96, 95%CI 0.40-2.79 and OR 0.58, 95%CI 0.25-1.36, respectively). It should be noted that the degree of surgical delay did not mitigate this bleeding risk, and there was no difference in the rate of postoperative thromboembolism, either.…”

“…There is growing evidence supporting early hip fracture surgery (within 6-48 hours) in patients treated with DOACs; the particular drug, dose taken, timing of the last dose, function and, when available, the level of coagulation should be taken into consideration [126,127,134]. Three recent cohort studies showed that the intraoperative blood loss or intra or postoperative transfusion rate was not different for patients under DOAC treatment undergoing early surgery for hip fracture (≤ 24-48 h) compared with controls [139][140][141].…”