Pharmacologic Reversal of Warfarin-Associated Coagulopathy in Geriatric Patients With Hip Fractures

Abstract

Purpose: Patients with acute hip fractures who are on maintenance warfarin for anticoagulation present a significant challenge and their management remains controversial. The purpose of this study was to assess thromboembolic and systemic complications associated with pharmacological reversal of warfarin-associated coagulopathy in a population of geriatric patients with hip fractures. Methods: This retrospective cohort study identified patients with operative hip fractures on oral warfarin therapy who had an international normalized ratio (INR) >1.50 on admission (N ¼ 93) approximately over a 13-year span. The control group consisted of patients whose warfarin was held upon admission without further intervention preoperatively (n ¼ 23). The treatment group consisted of patients who underwent pharmacologic reversal of elevated INR with vitamin K and/or fresh frozen plasma (FFP) in addition to holding warfarin (n ¼ 70). Primary outcomes included thromboembolic and other complications as well as mortality within 3 months of presentation. Time to surgery was a secondary outcome. Results: The 3-month mortality rate was 4% in the pharmacological intervention group and 17% in the watch-and-wait group; this difference trended toward statistical significance (P ¼ .06). There were no significant differences in the likelihoods of other thromboembolic or nonthromboembolic complications between groups. While the difference in mean time to surgery was not significantly different overall between groups, this difference was significant in a subgroup of patients with higher baseline INRs (n ¼ 46, INR >2.17), with a mean difference of 4.0 fewer days until surgery in the pharmacological intervention group (P < .01). Conclusions: Pharmacological reversal of warfarin-associated coagulopathy with a combination of vitamin K and FFP appears to be a safe way to optimize patients for operative fixation of hip fractures and is associated with a shorter delay to surgery in patients with more elevated INRs preoperatively. Level of evidence: retrospective cohort study (level III).

Do Patients Taking Warfarin Experience Delays to Theatre, Longer Hospital Stay, and Poorer Survival After Hip Fracture?

“…Our study is the most comprehensive to date to show association between warfarin therapy and delays to the operating room, and therefore should highlight the need to prevent any avoidable preoperative delays in these patients. Early warfarin reversal together with adequate investigation and optimization of these more complex patients could ensure timely, safe surgery [2, 7–9, 23, 26]. …”

Anticoagulation therapy and proximal femoral fracture treatment

“…Vitale et al 8 conducted a study among 1634 patients presenting to the Columbia Presbyterian Medical Centre (CPMC) between 1997 and 2010, who underwent operative intervention of a hip fracture. Of these, 93 patients (5.7%) were identified as having a pre-operative international normalised ratio (INR) >1.50 and were taking warfarin on admission.…”

“…The authors concluded that reversal of warfarin-associated coagulopathy with vitamin K and/or FFP is not associated with a greater rate of post-operative complications in the high-risk geriatric population of patients with hip fractures and was found to be a safe alternative to warfarin cessation alone, which may result in increased delay to surgery. 8 …”

“…8 There is a risk of significant bleeding if aspirin is taken in combination with other thromboprophylactic medication. Aspirin may be withheld during inpatient stay unless indicated for unstable angina or recent/frequent transient ischaemic attacks.…”

“…The time to surgery was reduced with continuous positive consequences, including a reduction in LOS and development of post-operative complications. 8-10,16 …”