Morbidity and mortality after fragility hip fracture surgery in patients receiving vitamin K antagonists and direct oral anticoagulants

Rutenberg, Tal Frenkel; Velkes, Steven; Vitenberg, Maria; Leader, Avi; Halavy, Yael; Raanani, Pia; Yassin, Mustafa; Spectre, Galia

doi:10.1016/j.thromres.2018.04.022

Cited by 42 publications

(42 citation statements)

References 26 publications

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“…3 - 7 While Warfarin can be easily reversed and reliably monitored, DOACs prove more difficult to reverse and have no clear biochemical markers to allow therapeutic monitoring. 8 - 10 Reversal agents are available for Dabigatran (Idarucizumab), Apixaban, and Rivaroxaban (Andexanet alfa), however, are expensive and generally reserved for emergencies. 7 , 10 Consequently, surgical delay to allow drug clearance is the only feasible option to reverse the anticoagulant effects of DOACs.…”

Section: Introductionmentioning

confidence: 99%

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Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study

King

Polischuk

Lynch

et al. 2020

Geriatr Orthop Surg Rehabil

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Introduction: Currently, evidence-based guidelines regarding delay to theatre for urgent surgical intervention in patients taking direct oral anticoagulants (DOACs) are lacking. Therefore, this study aims to investigate the effect of DOACs on patient outcomes receiving early (<48 hours) versus delayed (>48 hours) surgery for neck of femur fractures. Methods: A retrospective cohort study was conducted at a tertiary teaching hospital. Treatment groups were hip fracture patients taking DOACs on admission and receiving surgery in <48 hours (n = 17) and >48 hours (n = 11). A control cohort of hip fracture patients not taking DOACs (n = 56) was matched to the <48 hours treatment group for comparison. Patient demographics were recorded and key outcome measures included perioperative hemoglobin levels, transfusion rates, time to surgery, 90-day mortality, hematoma rates, and length of stay in hospital. Results: There was no significant difference in perioperative hemoglobin levels, transfusion rates, or hematoma between groups. Patients taking DOACs and receiving early surgery had significantly longer time to surgery compared to the non-DOAC control (32.21 ± 7.83 vs 25.98 ± 11.4, P = .01). No deaths were recorded in the early DOAC group at 90 days, compared to 4 (36%) in the late DOAC group ( P = .04). Discussion and Conclusions: Our study suggests hip fracture patients taking DOACs on admission is not a reason to delay surgery. However, given the lack of literature in this area, further prospective research with larger patient numbers is required to definitively guide clinical practice.

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Section: Introductionmentioning

confidence: 99%

“…Average time to surgery for DOAC patients has been shown to vary from 35 hours to 66.9 hours. 9 , 20 , 21 …”

Section: Introductionmentioning

confidence: 99%

Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study

King

Polischuk

Lynch

et al. 2020

Geriatr Orthop Surg Rehabil

View full text Add to dashboard Cite

show abstract

“…The study has larger numbers than the existing literature (n = 7 [6], n = 19 [7], n = 27 [8], n = 28 [9], n = 29 [10], n = 33 [16], n = 47 [11], n = 52 [15], n = 54 [12], n = 63 [13] and n = 89 [14]). It also specifically focuses on assessing a dose-response relationship within a cohort taking DOACs; this approach avoids the potential bias of finding a suitable non-DOAC control group and should be considered for future studies.…”

Section: Discussionmentioning

confidence: 93%

“…The existing literature compares hip fracture groups with matched cohorts not taking anticoagulants [7][8][9][11][12][13][14] or groups' DOACs with other antithrombotics without separate analysis [6,10]. The most common management question asked by clinicians is ''what is the safest window to operate?".…”

Section: Discussionmentioning

confidence: 99%

“…National pharmaceutical subsidies have resulted in a steady increase in usage [5]. The existing literature examining DOAC use in hip fracture is small [6][7][8][9][10][11][12][13][14][15][16], and often focuses on comparing DOAC cohorts with groups not taking them, which results in differences between group comorbidity profiles. The appropriate perioperative management for DOACs in hip fracture has been recently queried [17], with expert opinion suggesting a waiting period of 24-48 hours, based on DOAC half-lives and guidelines for elective surgery [18].…”

Section: Introductionmentioning

confidence: 99%

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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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Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

Mitchell

Jakobs

Halim

et al. 2022

Eur J Trauma Emerg Surg

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Purpose To synthesise the evidence on the impact of pre-operative direct oral anticoagulants (DOACs) on health outcomes for patients who sustain a hip fracture. Method A rapid systematic review of three databases (MEDLINE, Embase and Scopus) for English-language articles from January 2000 to August 2021 was conducted. Abstracts and full text were screened by two reviewers and articles were critically appraised. Data synthesis was undertaken to summarise health outcomes examined for DOAC users versus a no anticoagulant group. Key information was extracted for study type, country and time frame, population and sample size, type of DOACs, comparator population(s), key definitions, health outcome(s), and summary study findings. Results There were 21 articles identified. Of the 18 studies that examined time to surgery, 12 (57.1%) found DOAC users had a longer time to surgery than individuals not using anticoagulants. Five (83.3%) of six studies identified that DOAC users had a lower proportion of surgery conducted within 48 h Four (40.0%) of ten studies reporting hospital length of stay (LOS) identified a higher LOS for DOAC users. Where reported, DOAC users did not have increased mortality, blood loss, transfusion rates, complication rates of stroke, re-operation or readmissions compared to individuals not using anticoagulants. Conclusions The effect of DOAC use on hip fracture patient health was mixed, although patients on DOACs had a longer time to surgery. The review highlights the need for consistent measurement of health outcomes in patients with a hip fracture to determine the most appropriate management of patients with a hip fracture taking DOACs.

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Morbidity and mortality after fragility hip fracture surgery in patients receiving vitamin K antagonists and direct oral anticoagulants

Cited by 42 publications

References 26 publications

Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study

Early Surgical Fixation for Hip Fractures in Patients Taking Direct Oral Anticoagulation: A Retrospective Cohort Study

Direct Oral Anticoagulants and Timing of Hip Fracture Surgery

Synthesis of the evidence on the impact of pre-operative direct oral anticoagulants on patient health outcomes after hip fracture surgery: rapid systematic review

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